1
|
Da Silva I, Orozco-Guillén A, Longhitano E, Ballarin JA, Piccoli GB. Pre-gestational counselling for women living with CKD: starting from the bright side. Clin Kidney J 2024; 17:sfae084. [PMID: 38711748 PMCID: PMC11070880 DOI: 10.1093/ckj/sfae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Indexed: 05/08/2024] Open
Abstract
Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.
Collapse
Affiliation(s)
- Iara Da Silva
- Nephrology Department, Germans Trias i Pujol University Hospital, Badalona, Barcelona, Spain
| | - Alejandra Orozco-Guillén
- Department of intersive medical care, Isidro Espinosa de los Reyes National Perinatology Institute, Mexico City, Mexico
| | | | | | | |
Collapse
|
2
|
Hebert JF, Funahashi Y, Emathinger JM, Nickerson MN, Groat T, Andeen NK, Gurley SB, Hutchens MP. Parental recovered acute kidney injury causes prenatal renal dysfunction and fetal growth restriction with sexually dimorphic implications for adult offspring. Front Physiol 2024; 15:1357932. [PMID: 38681142 PMCID: PMC11045984 DOI: 10.3389/fphys.2024.1357932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction: Acute kidney injury (AKI) is rapidly increasing in global incidence and a healthcare burden. Prior maternal AKI diagnosis correlates with later pregnancy complications. As pregnancy influences developmental programming, we hypothesized that recovered parental AKI results in poor pregnancy outcomes, impaired fetal growth, and adult offspring disease. Methods: Using a well-characterized model of rhabdomyolysis-induced acute kidney injury (RIAKI), a form of AKI commonly observed in young people, we confirmed functional renal recovery by assessing glomerular filtration rate (GFR) 2 weeks following RIAKI. We bred sham and recovered RIAKI sires and dams in timed, matched matings for gestational day (GD) 16.5 and offspring (birth-12 weeks, 6 months) study. Results: Despite a normal GFR pre-pregnancy, recovered RIAKI dams at GD16.5 had impaired renal function, resulting in reduced fetoplacental ratios and offspring survival. Pregnant RIAKI dams also had albuminuria and less renal megalin in the proximal tubule brush border than shams, with renal subcapsular fibrosis and higher diastolic blood pressure. Growth-restricted offspring had a reduced GFR as older adults, with evidence of metabolic inefficiency in male offspring; this correlated with reduced renal AngII levels in female offspring from recovered RIAKI pairings. However, the blood pressures of 6-month-old offspring were unaffected by parental RIAKI. Conclusions: Our mouse model demonstrated a causal relationship among RIAKI, gestational risk, and developmental programming of the adult-onset offspring GFR and metabolic dysregulation despite parental recovery.
Collapse
Affiliation(s)
- Jessica F. Hebert
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Yoshio Funahashi
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, United States
| | | | - Megan N. Nickerson
- Operative Care Division, Portland Veterans Administration Medical Center, Portland, OR, United States
| | - Tahnee Groat
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Nicole K. Andeen
- Department of Pathology, Oregon Health and Science University, Portland, OR, United States
| | - Susan B. Gurley
- Division of Nephrology and Hypertension, Department of Medicine, Keck School Medicine of University of Southern California, Los Angeles, CA, United States
| | - Michael P. Hutchens
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, United States
- Operative Care Division, Portland Veterans Administration Medical Center, Portland, OR, United States
| |
Collapse
|
3
|
Piccoli GB, Attini R, Torreggiani M, Chatrenet A, Manzione AM, Masturzo B, Casula V, Longhitano E, Dalmasso E, Biancone L, Pani A, Cabiddu G. Any reduction in maternal kidney mass makes a difference during pregnancy in gestational and fetal outcome. Kidney Int 2024; 105:865-876. [PMID: 38296027 DOI: 10.1016/j.kint.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 11/29/2023] [Accepted: 12/15/2023] [Indexed: 02/19/2024]
Abstract
Little is known about the effect tubulointerstitial nephropathies have in modulating maternal-fetal outcomes in pregnancy. Therefore, we analyzed the main outcomes of pregnancy in these women to gain a better understanding of the role of a reduction in maternal kidney mass. From the Torino Cagliari Observational Study (TOCOS) cohort, we selected 529 patients with a diagnosis of tubulointerstitial disease and focused on 421 patients with chronic kidney disease (CKD) stage 1, without hypertension but with proteinuria less than 0.5 g/day at referral. From a cohort of 2969 singleton deliveries from low-risk pregnancies followed in the same settings we selected a propensity score matched control cohort of 842 pregnancies match 2:1 for age, parity, body mass index, ethnicity, and origin. Time to delivery was significantly shorter in the study cohort 38.0 (Quartile 1-Quartile 3: 37.0-39.0) versus 39.0 (Q1-Q3 38.0-40.0) weeks, with respect to controls. Incidence of delivery of less than 37 gestational weeks significantly increased from controls (7.4%) to women with previous acute pyelonephritis (10.8%), other tubulointerstitial diseases (9.7%) and was the highest in patients with a single kidney (31.1%). Similarly, neonatal birthweight significantly and progressively decreased from controls (3260 g [Q1-Q3: 2980-3530]), previous acute pyelonephritis (3090 g [Q1-Q3: 2868-3405], other tubulointerstitial diseases (3110 g [Q1-Q3: 2840-3417]), and to solitary kidney (2910 g [Q1-Q3: 2480-3240]). Risk of developing preeclampsia was significantly higher in the CKD cohort (3.6% vs 1.7% in low-risk controls). Thus, even a small reduction in functional kidney mass, such as a pyelonephritic scar, is associated with a shorter duration of pregnancy and an increased risk of preterm delivery. The risk is proportional to the extent of parenchymal reduction and is highest in cases with a solitary kidney.
Collapse
Affiliation(s)
| | - Rossella Attini
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | | | - Antoine Chatrenet
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; APCoSS-Institute of Physical Education and Sports Sciences (IFEPSA), UCO Angers, Angers, France
| | - Ana Maria Manzione
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Bianca Masturzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Viola Casula
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | - Elisa Longhitano
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. "G. Martino", University of Messina, Messina, Italy
| | - Eleonora Dalmasso
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Luigi Biancone
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Antonello Pani
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | - Gianfranca Cabiddu
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| |
Collapse
|
4
|
Hebert JF, Funahashi Y, Hutchens MP. Harm! foul! How acute kidney injury SHReDDs patient futures. Curr Opin Nephrol Hypertens 2023; 32:165-171. [PMID: 36683541 PMCID: PMC10079264 DOI: 10.1097/mnh.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Transition from acute kidney injury (AKI) to chronic kidney disease (CKD) is increasingly accepted. Less well recognized, but supported by very similar data, is development of disease of other organ systems after AKI. Awareness of other-organ sequelae of AKI may inform efforts to improve the care of patients after AKI. RECENT FINDINGS Stroke, hypertension, reproductive risk, dementia, and death (SHReDD) are sequelae, which occur with increased risk relative to that of non-AKI within 6 months-3 years after AKI diagnosis, and which are supported by preclinical/mechanistic study. Adjusted hazard ratios for these sequelae are strikingly similar to that of AKI-CKD, ranging from 1.2 to 3.0. Mechanistic studies suggest kidney-centric mechanisms including sodium regulation, volume status regulation, and the renin-angiotensin system are drivers of long-term, extra-renal, change. SUMMARY Further clinical characterization and mechanistic insight is necessary, and may have considerable translational impact. Programs which screen or follow post-AKI patients may increase clinical utility if focus is expanded to include the SHReDD complications.
Collapse
Affiliation(s)
- Jessica F Hebert
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University
| | - Yoshio Funahashi
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University
| | - Michael P Hutchens
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University
- Operative Care Division, Portland Veterans Administration Medical Center, Portland, Oregon, USA
| |
Collapse
|
5
|
Sciscent BY, Bhanja D, Daggubati LC, Ryan C, Hallan DR, Rizk EB. Pregnancy in spina bifida patients: a comparative analysis of peripartum procedures and complications. Childs Nerv Syst 2023; 39:625-632. [PMID: 36278978 DOI: 10.1007/s00381-022-05705-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Spina bifida (SB) is caused by a failure in neural tube closure that can present with lower extremity sensory deficits, paralysis, and hydrocephalus. Medical advances have allowed increased pregnancies among SB patients, but management and pregnancy-associated complications have not been thoroughly investigated. The objective is to delineate peripartum procedures and complications in patients with SB. METHODS A national de-identified database, TriNetX, was retrospectively queried to evaluate pregnant SB patients and the general population. Procedures and complications were investigated using corresponding ICD-10 and CPT codes within 1 year of pregnancy diagnosis. RESULTS 11,405 SB patients were identified and compared to 9,269,084 non-SB patients. SB patients were significantly more likely to undergo cesarean delivery (1.200; 95% CI [1.133-1.271]) and less likely to receive neuraxial analgesia (0.406; 95% CI [0.383-0.431]). Additionally, patients with SB had an increased risk of seizures (3.922; 95% CI [3.529-4.360]) and venous thromboembolism (VTE) (3.490; 95% CI [3.070-3.969]). Risks of preeclampsia and hemorrhage were comparable. SB patients with hydrocephalus and Chiari malformation type 1 (CM-1) or type 2 (CM-2) were compared to patients without these comorbid conditions. This sub-group analysis showed a significantly increased risk of having cesarean deliveries (SB with hydrocephalus: 12.55%, S.B. with CM-1 or CM-2: 12.81% vs. SB without hydrocephalus or CM, 6.16%) and VTE (3.74%, 2.43% vs. 0.81%). There were also increased risks of hemorrhage and seizures and decreased use of neuraxial analgesia, but the sample size was insufficient. CONCLUSION SB patients were more likely to undergo cesarean section and exhibit peripartum complications compared to those without SB.
Collapse
Affiliation(s)
- Bao Y Sciscent
- Department of Neurosurgery, Penn State Health, Hershey, PA, 17033, USA.
- Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA.
| | - Debarati Bhanja
- Department of Neurosurgery, Penn State Health, Hershey, PA, 17033, USA
- Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | | | - Casey Ryan
- Department of Neurosurgery, Penn State Health, Hershey, PA, 17033, USA
| | - David R Hallan
- Department of Neurosurgery, Penn State Health, Hershey, PA, 17033, USA
| | - Elias B Rizk
- Department of Neurosurgery, Penn State Health, Hershey, PA, 17033, USA
| |
Collapse
|
6
|
Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
Collapse
Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
| | | |
Collapse
|
7
|
Dines V, Suvakov S, Kattah A, Vermunt J, Narang K, Jayachandran M, Abou Hassan C, Norby AM, Garovic VD. Preeclampsia and the Kidney: Pathophysiology and Clinical Implications. Compr Physiol 2023; 13:4231-4267. [PMID: 36715282 DOI: 10.1002/cphy.c210051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.
Collapse
Affiliation(s)
- Virginia Dines
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Sonja Suvakov
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jane Vermunt
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Kavita Narang
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Coline Abou Hassan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander M Norby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
8
|
Gupta M, Yadav P, Yaqoob F. A Prospective Study to Determine the Predictive Ability of HDP-Gestosis Score for the Development of Pre-eclampsia. J Obstet Gynaecol India 2022; 72:485-491. [PMID: 36158863 PMCID: PMC9483246 DOI: 10.1007/s13224-022-01704-0] [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: 03/19/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
Background HDP-gestosis score is a risk scoring system (score 1-3) for the development of pre-eclampsia. When a pregnant woman's total score is equal to or greater than 3, she is labelled as "at risk for pre-eclampsia" and is managed accordingly. Objectives To determine the sensitivity, specificity, Positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of HDP-gestosis score for predicting pre-eclampsia. Methods This prospective study included 473 pregnant women who presented at the department of Obstetrics and Gynaecology, from June 2020 to December 2021. After 20 weeks of pregnancy, the patients were assessed for the development of pre-eclampsia. Details of age, gravida, obstetric history, menstrual cycle regularity, polycystic ovarian disease history, duration of marriage, parity, past medical and surgical intervention, previous/present medication, and family history were taken. Gestosis score was calculated and classified into mild (score of 1), moderate (score of 2) and high risk (score of ≥ 3) for the development of Pre-eclampsia (PE). Sensitivity, Specificity, PPV, NPV and diagnostic accuracy of HDP-gestosis score for predicting the development of PE were determined. Results The mean age, gestational age, and BMI of the women were 28.4 ± 6.8 years, 11.5 ± 2.04 weeks, and 24.5 ± 3.7 kg/m2, respectively. The gestosis score was 2 in 43.13% of the participants, 1 in 42.28%, and ≥ 3 in 14.59% of the women. PE developed in 15.01% (n = 71) participants. The Sensitivity, Specificity, PPV, NPV, and Diagnostic accuracy of HDP-gestosis score for predicting PE were 83.1%, 97.51%, 85.51%, 97.03% and 95.35%, respectively. Conclusion Gestosis score is a novel early marker for prediction of the development of PE allowing for a prompt management for the patients, thereby curbing the adverse consequences.
Collapse
Affiliation(s)
- Meeta Gupta
- Department of Obstetrics and Gynaecology, AIIMS, F-311, Sainik Colony, Jammu, India
| | - Poonam Yadav
- Department of Obstetrics and Gynaecology, S.N Medical College, Agra, U.P India
| | - Farhana Yaqoob
- Department of Obstetrics and Gynaecology, ASCOMS, Jammu, Jammu and Kashmir 180011 India
| |
Collapse
|
9
|
Dupont V, Berg AH, Yamashita M, Huang C, Covarrubias AE, Ali S, Stotland A, Van Eyk JE, Jim B, Thadhani R, Karumanchi SA. Impaired renal reserve contributes to preeclampsia via the kynurenine and soluble fms-like tyrosine kinase 1 pathway. J Clin Invest 2022; 132:158346. [PMID: 35943814 PMCID: PMC9566901 DOI: 10.1172/jci158346] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
To understand how kidney donation leads to an increased risk of preeclampsia, we studied pregnant outbred mice with prior uninephrectomy and compared them with sham-operated littermates carrying both kidneys. During pregnancy, uninephrectomized (UNx) mice failed to achieve a physiological increase in the glomerular filtration rate and during late gestation developed hypertension, albuminuria, glomerular endothelial damage, and excess placental production of soluble fms-like tyrosine kinase 1 (sFLT1), an antiangiogenic protein implicated in the pathogenesis of preeclampsia. Maternal hypertension in UNx mice was associated with low plasma volumes, an increased rate of fetal resorption, impaired spiral artery remodeling, and placental ischemia. To evaluate potential mechanisms, we studied plasma metabolite changes using mass spectrometry and noted that l-kynurenine, a metabolite of l-tryptophan, was upregulated approximately 3-fold during pregnancy when compared with prepregnant concentrations in the same animals, consistent with prior reports suggesting a protective role for l-kynurenine in placental health. However, UNx mice failed to show upregulation of l-kynurenine during pregnancy; furthermore, when UNx mice were fed l-kynurenine in drinking water throughout pregnancy, their preeclampsia-like state was rescued, including a reversal of placental ischemia and normalization of sFLT1 levels. In aggregate, we provide a mechanistic basis for how impaired renal reserve and the resulting failure to upregulate l-kynurenine during pregnancy can lead to impaired placentation, placental hypoperfusion, an antiangiogenic state, and subsequent preeclampsia.
Collapse
Affiliation(s)
- Vincent Dupont
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.,EA-3801, Université de Reims Champagne-Ardenne, Reims, France
| | | | | | | | | | - Shafat Ali
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Aleksandr Stotland
- Department of Biomedical Sciences and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jennifer E. Van Eyk
- Department of Biomedical Sciences and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Belinda Jim
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ravi Thadhani
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - S. Ananth Karumanchi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
10
|
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.
Collapse
|
11
|
Pregnancy and Kidney Diseases: Multidisciplinary Follow-Up and the Vicious Circles Involving Pregnancy and CKD, Preeclampsia, Preterm Delivery and the Kidneys. J Clin Med 2022; 11:jcm11092535. [PMID: 35566661 PMCID: PMC9105432 DOI: 10.3390/jcm11092535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/29/2022] [Indexed: 02/05/2023] Open
|
12
|
Garovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, Rana S, Vermunt JV, August P. Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e21-e41. [PMID: 34905954 PMCID: PMC9031058 DOI: 10.1161/hyp.0000000000000208] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.
Collapse
|
13
|
Tyagi A, Yadav P, Salhotra R, Das S, Singh PK, Garg D. Acute Kidney Injury in Severe Preeclamptic Patients Admitted to Intensive Care Unit: Epidemiology and Role of Serum Neutrophil Gelatinase-associated Lipocalcin. Indian J Crit Care Med 2021; 25:1013-1019. [PMID: 34963719 PMCID: PMC8664012 DOI: 10.5005/jp-journals-10071-23966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Patients with preeclampsia admitted to the intensive care unit (ICU) may have risk factors for acute kidney injury (AKI). Although the use of neutrophil gelatinase-associated lipocalcin (NGAL) to predict AKI is previously validated, we could locate only scanty data regarding the epidemiology of AKI and role of NGAL in preeclamptic patients admitted to ICU. Methods Patients with preeclampsia admitted to our ICU were included. The incidence and severity of AKI during the entire ICU stay were assessed using kidney disease improving global outcomes criteria, while the a priori risk factors and serum NGAL were also evaluated. Results A total of 52 preeclamptic patients admitted to ICU were included, among whom the majority had eclampsia (75%). AKI developed in 25 (48.1%) patients with stages 1, 2, and 3 in 56, 36, and 8%, respectively. The incidence of sepsis (16 vs 0%), shock (40 vs 7.4%), and anemia (84 vs 59.3%) was significantly greater in patients with AKI (p < 0.05). ICU mortality (28 vs 3.7%), duration of ICU, and hospital stay were significantly higher in patients who developed AKI (p < 0.05). There was no association of serum NGAL [274 (240–335) ng/mL] with AKI or the mortality (p = 0.725, 0.861); there was, however, a significant discriminatory value for eclampsia [p = 0.019; area under curve = 0.736 (95% confidence interval: 0.569–0.904)]. Conclusions Although AKI is common among patients with preeclampsia admitted to ICU, serum NGAL does not predict its occurrence. How to cite this article Tyagi A, Yadav P, Salhotra R, Das S, Singh PK, Garg D. Acute Kidney Injury in Severe Preeclamptic Patients Admitted to Intensive Care Unit: Epidemiology and Role of Serum Neutrophil Gelatinase-associated Lipocalcin. Indian J Crit Care Med 2021;25(9):1013–1019.
Collapse
Affiliation(s)
- Asha Tyagi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Pooja Yadav
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Rashmi Salhotra
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Shukla Das
- Department of Microbiology, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Praveen K Singh
- Department of Microbiology, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Devansh Garg
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India
| |
Collapse
|
14
|
Shapiro J, Ray JG, McArthur E, Jeyakumar N, Chanchlani R, Harel Z, Arora R, Meraz-Munoz A, Garg AX, Hladunewich M, Wald R. Risk of Acute Kidney Injury After Hypertensive Disorders of Pregnancy: A Population-Based Cohort Study. Am J Kidney Dis 2021; 79:561-569. [PMID: 34487795 DOI: 10.1053/j.ajkd.2021.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/16/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Even though studies have demonstrated a relationship between hypertensive disorders of pregnancy (HDPs) and chronic kidney disease, there are limited data on the risk of acute kidney injury (AKI) following HDPs. We examined the risk of AKI following the occurrence of HDPs. STUDY DESIGN Retrospective population-based cohort study. SETTING & PARTICIPANTS Pregnant women in Ontario, Canada, aged 14-50 years, who delivered at ≥20 weeks' gestation between April 1, 2002, and March 31, 2015. EXPOSURE Preeclampsia, gestational hypertension, or neither. OUTCOMES The primary outcome was AKI with receipt of dialysis (AKI-D) ≥90 days after delivery. The main secondary outcome was AKI based on a hospitalization with a diagnostic code for AKI ≥90 days after delivery. ANALYTICAL APPROACH Time-dependent Cox proportional and cause-specific hazards models were used to evaluate the relationship between HDP and outcomes of interest. Models were adjusted for baseline and time-varying covariates. RESULTS Our cohort comprised 1,142,656 women and 1,826,235 deliveries, of which 1.7% were associated with gestational hypertension and 4.4% with preeclampsia. After a mean follow-up of 6.7 years, there were 322 episodes of AKI-D (0.41 per 10,000 person-years) and 1,598 episodes of AKI based on diagnostic codes (2.04 per 10,000 person-years). After adjustment, neither preeclampsia nor gestational hypertension was associated with AKI-D. Preeclampsia was associated with AKI (HR, 1.22 [95% CI, 1.03-1.45]), but gestational hypertension was not. LIMITATIONS Retrospective design and possible unmeasured confounding. Cases of HDPs and AKI may have been undetected. CONCLUSIONS Preeclampsia was a risk factor for AKI occurring ≥90 days after delivery. Our findings suggest the potential importance of obtaining a pregnancy history as part of a comprehensive risk profile for acute kidney disease and suggest that women with a history of HDP may benefit from monitoring of kidney function.
Collapse
Affiliation(s)
| | - Joel G Ray
- Departments of Medicine, Toronto; University of Toronto Divisions of General Internal Medicine, Toronto; Li Ka Shing Knowledge Institute, Toronto; ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada
| | - Eric McArthur
- ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, McMaster University, Hamilton; ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada
| | - Ziv Harel
- Departments of Medicine, Toronto; Nephrology, Toronto; Li Ka Shing Knowledge Institute, Toronto; ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada
| | | | | | - Amit X Garg
- ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada; Division of Nephrology, London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Michelle Hladunewich
- Departments of Medicine, Toronto; St. Michael's Hospital Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto
| | - Ron Wald
- Departments of Medicine, Toronto; Nephrology, Toronto; Li Ka Shing Knowledge Institute, Toronto; ICES (Institute of Clinical Evaluative Sciences), London, Ontario, Canada.
| |
Collapse
|
15
|
Gillis EE, Brands MW, Sullivan JC. Adverse Maternal and Fetal Outcomes in a Novel Experimental Model of Pregnancy after Recovery from Renal Ischemia-Reperfusion Injury. J Am Soc Nephrol 2021; 32:375-384. [PMID: 33408137 PMCID: PMC8054890 DOI: 10.1681/asn.2020020127] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 11/11/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recent clinical studies report that women with a history of AKI have an increased incidence of maternal and fetal adverse outcomes during pregnancy, despite fully recovering renal function prior to conception. The mechanisms contributing to such adverse outcomes in pregnancy after AKI are not yet understood. METHODS To develop a rodent model to investigate fetal and maternal outcomes in female animals with a history of AKI, we used ischemia-reperfusion injury as an experimental model of AKI in female Sprague Dawley rats. The 12-week-old animals underwent warm bilateral ischemia-reperfusion surgery involving clamping of both renal arteries for 45 minutes or sham surgery (control). Rats were allowed to recover for 1 month prior to mating. Recovery from ischemia-reperfusion injury was confirmed by measurements of plasma creatinine and urinary protein excretion. We assessed maternal and fetal outcomes during late pregnancy on gestational day 20. RESULTS After recovery from ischemia-reperfusion injury, compared with healthy sham-surgery controls, dams exhibited pregnancy-induced renal insufficiency with increases in plasma creatinine and urea, along with increased urinary protein excretion. Additionally, recovered ischemia-reperfusion dams experienced worse fetal outcomes compared with controls, with intrauterine growth restriction leading to higher rates of fetal demise and smaller pups. CONCLUSIONS In this rat model, despite biochemical resolution of ischemia-reperfusion injury, subsequent pregnancy resulted in maternal renal insufficiency and significant impairments in fetal growth. This mirrors findings in recent reports in the clinical population, indicating that this model may be a useful tool to further explore the alterations in kidney function after AKI in women.
Collapse
Affiliation(s)
- Ellen E Gillis
- Department of Physiology, Augusta University, Augusta, Georgia
| | | | | |
Collapse
|
16
|
Tangren JS, Thadhani R. Animal Model of Pregnancy after Acute Kidney Injury Mirrors the Human Observations. J Am Soc Nephrol 2021; 32:259-260. [PMID: 33408138 PMCID: PMC8054898 DOI: 10.1681/asn.2020121734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jessica Sheehan Tangren
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
17
|
Bakrania BA, Spradley FT, Drummond HA, LaMarca B, Ryan MJ, Granger JP. Preeclampsia: Linking Placental Ischemia with Maternal Endothelial and Vascular Dysfunction. Compr Physiol 2020; 11:1315-1349. [PMID: 33295016 PMCID: PMC7959189 DOI: 10.1002/cphy.c200008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Preeclampsia (PE), a hypertensive disorder, occurs in 3% to 8% of pregnancies in the United States and affects over 200,000 women and newborns per year. The United States has seen a 25% increase in the incidence of PE, largely owing to increases in risk factors, including obesity and cardiovascular disease. Although the etiology of PE is not clear, it is believed that impaired spiral artery remodeling of the placenta reduces perfusion, leading to placental ischemia. Subsequently, the ischemic placenta releases antiangiogenic and pro-inflammatory factors, such as cytokines, reactive oxygen species, and the angiotensin II type 1 receptor autoantibody (AT1-AA), among others, into the maternal circulation. These factors cause widespread endothelial activation, upregulation of the endothelin system, and vasoconstriction. In turn, these changes affect the function of multiple organ systems including the kidneys, brain, liver, and heart. Despite extensive research into the pathophysiology of PE, the only treatment option remains early delivery of the baby and importantly, the placenta. While premature delivery is effective in ameliorating immediate risk to the mother, mounting evidence suggests that PE increases risk of cardiovascular disease later in life for both mother and baby. Notably, these women are at increased risk of hypertension, heart disease, and stroke, while offspring are at risk of obesity, hypertension, and neurological disease, among other complications, later in life. This article aims to discuss the current understanding of the diagnosis and pathophysiology of PE, as well as associated organ damage, maternal and fetal outcomes, and potential therapeutic avenues. © 2021 American Physiological Society. Compr Physiol 11:1315-1349, 2021.
Collapse
Affiliation(s)
- Bhavisha A. Bakrania
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Frank T. Spradley
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Heather A. Drummond
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Babbette LaMarca
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael J. Ryan
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Joey P. Granger
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
18
|
Dines V, Kattah A. Hypertensive Disorders of Pregnancy. Adv Chronic Kidney Dis 2020; 27:531-539. [PMID: 33328070 DOI: 10.1053/j.ackd.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
Hypertensive disorders of pregnancy are increasing in incidence and are major causes of maternal morbidity and mortality both in the United States and worldwide. An understanding of these diseases is essential for the practicing nephrologist, as preexisting kidney disease is an important risk factor. In addition, the development of hypertensive disorders of pregnancy has important implications for long-term risk of kidney disease and cardiovascular disease. The definition and diagnostic criteria has changed in recent years as our understanding of the disease entity has progressed. Currently, proteinuria is no longer a necessary diagnostic feature of preeclampsia. Preeclampsia and gestational hypertension may develop through multiple different mechanisms. Current research suggests contributions of both placental factors and maternal factors contribute to the disease and represent different phenotypic presentations of preeclampsia.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW Pregnancy-related acute kidney injury (Pr-AKI) is associated with increased maternal and fetal morbidity and mortality and remains a large public health problem. RECENT FINDINGS Pr-AKI incidence has globally decreased over time for the most part. However, the cause presents a disparity between developing and developed countries, reflecting differences in socioeconomic factors and healthcare infrastructure - with the noteworthy outlier of increased incidence in the United States and Canada. Although Pr-AKI can be secondary to conditions affecting the general population, in most cases it is pregnancy specific. Septic abortion, hyperemesis gravidarum, and hemorrhage have become less prevalent with access to healthcare but are being displaced by thrombotic microangiopathies, such as preeclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, and pregnancy-associated hemolytic-uremic syndromes, as well as acute fatty liver of pregnancy. Understanding these conditions plays a pivotal role in the timely diagnosis and enhancement of therapeutic approaches. SUMMARY In this review, we focus on the renal physiology of the pregnancy, epidemiology, and specific conditions known to cause Pr-AKI, summarizing diagnostic definition, insights in pathophysiology, clinical considerations, and novel treatment approaches, thus providing the reader a framework of clinically relevant information for interdisciplinary management.
Collapse
|
20
|
Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens 2020; 19:94-99. [PMID: 31927326 DOI: 10.1016/j.preghy.2019.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/02/2019] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the prevalence of acute kidney injury (AKI), placental abruption and postpartum hemorrhage in patients with preeclampsia or HELLP syndrome. STUDY DESIGN A retrospective study of patients with preeclampsia or HELLP syndrome treated at the University of Mississippi Medical Center from January 2000 through December 2010. MAIN OUTCOME MEASURES Relationships among the obstetric complications of placental abruption, postpartum hemorrhage, and AKI (serum creatinine >107 µmol/L) of women with preeclampsia or HELLP syndrome. Additional analysis was undertaken to explore if there was a correlation between postpartum hemorrhage/placental abruption and the severity of HELLP syndrome according to the Mississippi classification system. RESULTS Data from 1276 women over 11 years were included in the analysis. 67 of 466 patients (14.4%) with HELLP syndrome and 38 of 810 preeclampsia patients (4.7%) met criteria for AKI. Women with either placental abruption or postpartum hemorrhage had statistically significant increased odds of also having AKI (p < 0.01). Women with HELLP and AKI were also more likely to experience either placental abruption or postpartum hemorrhage. Women with Class 1 HELLP with placental abruption or postpartum hemorrhage were also more likely to have AKI than women with preeclampsia. CONCLUSION HELLP syndrome, AKI and placental abruption or postpartum hemorrhage appear to be interrelated. AKI occurs more frequently in women with HELLP syndrome with or without associated postpartum hemorrhage and placental abruption.
Collapse
|
21
|
Conti-Ramsden FI, Nathan HL, De greeff A, Hall DR, Seed PT, Chappell LC, Shennan AH, Bramham K. Pregnancy-Related Acute Kidney Injury in Preeclampsia: Risk Factors and Renal Outcomes. Hypertension 2019; 74:1144-1151. [PMID: 31564161 PMCID: PMC6791560 DOI: 10.1161/hypertensionaha.119.13089] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/19/2019] [Accepted: 08/22/2019] [Indexed: 11/16/2022]
Abstract
Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 μmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6-11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8-2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21-4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.
Collapse
Affiliation(s)
- Frances I. Conti-Ramsden
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| | - Hannah L. Nathan
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| | | | - David R. Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa (D.R.H.)
| | - Paul T. Seed
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| | - Lucy C. Chappell
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| | - Andrew H. Shennan
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| | - K. Bramham
- From the Department of Women and Children’s Health, King’s College London, United Kingdom; (F.I.C-R., H.L.N., P.T.S., L.C.C., A.H.S., K.B.)
| |
Collapse
|
22
|
Anto EO, Roberts P, Coall D, Turpin CA, Adua E, Wang Y, Wang W. Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population. EPMA J 2019; 10:211-226. [PMID: 31462939 DOI: 10.1007/s13167-019-00183-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022]
Abstract
Background Normotensive pregnancy may develop into preeclampsia (PE) and other adverse pregnancy complications (APCs), for which the causes are still unknown. Suboptimal health status (SHS), a physical state between health and disease, might contribute to the development and progression of PE. By integration of a routine health measure in this Ghanaian Suboptimal Health Cohort Study, we explored the usefulness of a 25-question item SHS questionnaire (SHSQ-25) for early screening and prediction of normotensive pregnant women (NTN-PW) likely to develop PE. Methods We assessed the overall health status among a cohort of 593 NTN-PW at baseline (10-20 weeks gestation) and followed them at 21-31 weeks until 32-42 weeks. After an average of 20 weeks follow-up, 498 participants returned and were included in the final analysis. Hematobiochemical, clinical and sociodemographic data were obtained. Results Of the 498 participants, 49.8% (248/498) had 'high SHS' at baseline (61.7% (153/248) later developed PE) and 38.3% (95/248) were NTN-PW, whereas 50.2% (250/498) had 'optimal health' (17.6% (44/250) later developed PE) and 82.4% (206/250) were NTN-PW. At baseline, high SHS score yielded a significantly (p < 0.05) increased adjusted odds ratio, a wider area under the curve (AUC) and a higher sensitivity and specificity for the prediction of PE (3.67; 0.898; 91.9% and 87.8%), PE coexisting with intrauterine growth restriction (2.86, 0.838; 91.5% and 75.9%), stillbirth (2.52; 0.783; 96.6% and 60.0%), hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome (2.08; 0.800; 97.2% and 63.8%), acute kidney injury (2.20; 0.825; 95.3% and 70.0%) and dyslipidaemia (2.80; 0.8205; 95.7% and 68.4%) at 32-42 weeks gestation. Conclusions High SHS score is associated with increased incidence of PE; hence, SHSQ-25 can be used independently as a risk stratification tool for adverse pregnancy outcomes thereby creating an opportunity for predictive, preventive and personalized medicine.
Collapse
Affiliation(s)
- Enoch Odame Anto
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia.,2Department of Molecular Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Roberts
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | - David Coall
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | | | - Eric Adua
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | - Youxin Wang
- 4Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Wei Wang
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia.,4Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,5School of Public Health, Taishan Medical University, Taian, China
| |
Collapse
|
23
|
Chronic kidney disease in preeclamptic patients: not found unless searched for—Is a nephrology evaluation useful after an episode of preeclampsia? J Nephrol 2019; 32:977-987. [DOI: 10.1007/s40620-019-00629-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022]
|
24
|
Samejima T, Yamashita T, Takeda Y, Adachi T. Low antithrombin levels accompanied by high urine protein/creatinine ratios are predictive of acute kidney injury among CS patients with preeclampsia. J Matern Fetal Neonatal Med 2019; 34:1550-1556. [PMID: 31269838 DOI: 10.1080/14767058.2019.1639662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Previous acute kidney injury (AKI) is reportedly a risk factor for future preeclampsia (PE), and PE in current pregnancies may trigger the onset of AKI. In this study, we identified risk factors for AKI among Cesarean section (CS) patients with PE. METHODS We performed a retrospective study at a single center. Among 4602 deliveries between January 2017 and July 2018, 944 women underwent CS. Of these, 90 women had hypertensive disorders during their pregnancies, with 53 diagnoses of PE and 37 diagnoses of gestational hypertension. Medical records of the 90 women were reviewed retrospectively. RESULTS The rate of AKI was significantly higher in the PE group than in the GH group (17 versus 3%, p < .05). Univariate analyses of the PE group identified low preoperative serum albumin levels, low antithrombin III (ATIII) activities, and urine protein/creatinine ratios (U-P/Cr) as significant predictors of AKI. Cutoff values for these factors were calculated using ROC analyses, and the combination of ATIII and U-P/Cr, which were poorly correlated, was predictive of AKI. Specifically, the proportion of AKI in patients with low ATIII-high U-P/Cr was 50% (7/14), higher than that among patients with high ATIII-low U-P/Cr (0%, 0/19, p < .05), low ATIII-low U-P/Cr (10%, 1/10, p < .05), and high ATIII-high U-P/Cr (10%, 1/10, p < .05). CONCLUSIONS These data demonstrate that lower preoperative serum albumin levels, ATIII activities, and heavy proteinuria among CS patients with PE are risk factors for AKI.
Collapse
Affiliation(s)
- Taiki Samejima
- Department of Obstetrics and Gynecology, Aiiku Hospital, Tokyo, Japan
| | | | - Yoshiharu Takeda
- Department of Obstetrics and Gynecology, Aiiku Hospital, Tokyo, Japan
| | - Tomoko Adachi
- Department of Obstetrics and Gynecology, Aiiku Hospital, Tokyo, Japan
| |
Collapse
|
25
|
Hypertension Editors' Picks Preeclampsia. Hypertension 2019; 74:e6-e21. [PMID: 31154866 DOI: 10.1161/hypertensionaha.119.13233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
26
|
Affiliation(s)
- Sarosh Rana
- From the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL (S.R.)
| | - Elizabeth Lemoine
- Harvard Medical School, Boston, MA (E.L.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
| | - Joey P. Granger
- Department of Physiology, University of Mississippi Medical Center, Jackson (J.P.G.)
| | - S. Ananth Karumanchi
- Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (S.A.K.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
| |
Collapse
|