Renal function studies in toxemia of pregnancy; excretion of solutes and renal hemodynamics during osmotic diuresis in hydropenia

Serum levels of uric acid may have a potential role in the management of immediate delivery or prolongation of pregnancy in severe preeclampsia

OBJECTIVE

To investigate the biomarker(s) that could affect the decision for immediate or delayed delivery in severe preeclampsia.

METHODS

Data on serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), creatinine, blood urea nitrogen (BUN), uric acid (UA) and platelet counts from 134 cases were collected and analysed.

RESULTS

Higher UA levels were seen in case with immediate delivery. Higher stillbirth was seen in cases with delayed delivery.

CONCLUSION

UA levels could be a potential management biomarker for immediate or delayed delivery in severe preeclampsia. However, the higher risk of stillbirth must be considered in delayed delivery.

The Role of Uric Acid in Preeclampsia: Is Uric Acid a Causative Factor or a Sign of Preeclampsia?

PURPOSE OF REVIEW

Because of the significant discrepancies on this topic, this review will focus on the role of uric acid in PE, uric acid as a predictor of preeclampsia and fetal growth retardation. We considered eligible review and original articles relevant to the research question.

RECENT FINDINGS

Hypertensive disorders of pregnancy such as preeclampsia (PE) are a major cause of both maternal and fetal morbidity and mortality worldwide. Uric acid has been reported as a key factor contributing to the pathogenesis of PE. Some studies have indicated that serum uric acid levels increase with the severity of PE, while several studies have shown contradictory results. Some studies suggested high uric acid levels lead to PE, while others state that PE causes an increase in uric acid levels. Despite the strong association of uric acid in the pathogenesis of preeclampsia, current data is still contradictory hence genetic and high-end laboratory investigations may clarify this enigma.

Why kidneys fail post-partum: a tubulocentric viewpoint

Kidneys may fail post-partum in a number of circumstances due, for example, to post-partum haemorrhage, preeclampsia, amniotic fluid embolism or septic abortion. All these conditions in pregnancy and post partum represent a threat not only to the endothelium but also to the renal tubular epithelium, and as such may lead to rapid and also irreversible impairment of the renal function. This paper is a non-systematic review of the literature and of our experience, in which we discuss the main open issues on kidney disease in pregnancy and following delivery, in particular as regards tubular damage, with the aim to help reasoning on acute kidney injury (AKI) following delivery. The review will emphasize the often under-estimated importance of the tubular epithelium in the peri-partum period and will: (1) describe the main characteristics of the renal tissues around delivery; (2) define pregnancy-related AKI according to recent Kidney Disease/Improving Global Outcome (KDIGO) guidelines; (3) discuss the most common circumstances of post-partum AKI; and (4) describe the input expected from urinalysis, renal imaging and kidney biopsy.

Proteinuria in preeclampsia: Not essential to diagnosis but related to disease severity and fetal outcomes

Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality globally and proteinuria can be one of the cardinal features of this disease. However, studies about the association of the amount of proteinuria and the severity of preeclampsia, and perinatal outcomes are limited. Data on 239 women with preeclampsia were retrospectively collected from a university teaching hospital from September 2011 to June 2013 and analysed. Data included all clinical parameters and proteinuria in a 24h urine collection. In cases of severe preeclampsia, significantly fewer patients had proteinuria levels <0.3g/L in comparison to any of the other groups with proteinuria >0.3g/L, but there was no difference in cases of severe preeclampsia when proteinuria levels were >0.3g/L. Furthermore, when proteinuria levels were >0.3g/L, the frequency of severe preeclampsia in each group was significantly higher than the frequency of mild pre-eclampsia cases. Time of onset was significantly earlier in patients with proteinuria >3g/L in a 24h urine collection, but time between the onset of preeclampsia and delivery was not correlated with the amount of proteinuria. The birth weight was significantly lower in patients with proteinuria >3g/L. The incidence of fetal growth restriction or stillbirth was significantly higher in patients with proteinuria >5g/L. Our data demonstrate that the amount of proteinuria is not associated with the severe of preeclampsia, once proteinuria is detected, but is related to the severity of preeclampsia. The adverse fetal outcomes appear to be the function of prematurity rather than proteinuria itself.

An analysis of the differences between early and late preeclampsia with severe hypertension

Preeclampsia is clinically divided into early onset and late onset preeclampsia based on the gestational age at delivery. Although the diagnostic criteria are the same in each subgroup of preeclampsia, it has been suggested that the maternal and perinatal mortalities of early onset and late onset preeclampsia are different. However, studies that compare clinical parameters or laboratory biomarkers between early onset and late onset preeclampsia are limited. Data on 177 women with early or late preeclampsia with severe hypertension were collected from a University Teaching Hospital from January 2010 to January 2011 and analysed. Data included all the clinical parameters and laboratory biomarkers of liver and renal function. 63 women and 114 women were diagnosed with early and late preeclampsia with severe hypertension, respectively. There was no difference in the maternal age and the incidence of clinical symptoms including edema, vision disturbance, severe headache and stillbirth between two groups. There was a decrease in alkaline phosphatase levels in early preeclampsia with severe hypertension but other markers of liver function were not altered. However, renal function including blood urea nitrogen, creatinine and uric acid were significantly higher in early preeclampsia with severe hypertension. Umbilical artery systolic velocity/diastolic velocity ratio was significantly higher in early preeclampsia with severe hypertension. Our data demonstrates that the laboratory biomarkers of renal function differ between early and late preeclampsia with severe hypertension. The severity of renal dysfunction correlated with the time of delivery in preeclampsia with severe hypertension.

Serum uric acid may not be involved in the development of preeclampsia

Higher serum levels of uric acid are associated with preeclampsia and may signal an early change in preeclampsia. However there is less evidence suggesting there is a meaningful association between uric acid and the development of preeclampsia. A total of 877 women with preeclampsia at presentation and 580 normotensive pregnancies were retrospectively recruited from January 2009 to May 2014. In addition, 5556 pregnant women were also prospectively recruited from September 2012 to December 2013. Retrospective serum levels of uric acid were obtained from women with preeclampsia at the time of presentation (n=877), and serum levels of uric acid in the first, second and third trimester were prospectively collected in women who later developed preeclampsia (n=78), as well as those who did not (n=5478). The serum levels of uric acid were significantly increased in women with preeclampsia at presentation from retrospective samples and this increase correlated with the time of onset and the severity of preeclampsia. However, in prospective samples, serum levels of uric acid were not increased in the first and second trimesters in women who later developed preeclampsia compared with those who did not. The serum level of uric acid in the first and second trimesters in women who developed preeclampsia was not different. Our results demonstrate that the serum levels of uric acid were only increased after the presentation of clinical symptoms of preeclampsia. Therefore, it is likely that uric acid is not involved in the development of preeclampsia and cannot be an early prediction biomarker of this disease.

The renal circulation in normal pregnancy and preeclampsia: is there a place for relaxin?

During the first trimester of human pregnancy, the maternal systemic circulation undergoes remarkable vasodilation. The kidneys participate in this vasodilatory response resulting in marked increases in renal plasma flow (RPF) and glomerular filtration rate (GFR). Comparable circulatory adaptations are observed in conscious gravid rats. Administration of the corpus luteal hormone relaxin (RLN) to nonpregnant rats and humans elicits vasodilatory changes like those of pregnancy. Systemic and renal vasodilation are compromised in midterm pregnant rats by neutralization or elimination of circulating RLN and in women conceiving with donor eggs who lack a corpus luteum and circulating RLN. Although RLN exerts both rapid (minutes) and sustained (hours to days) vasodilatory actions through different molecular mechanisms, a final common pathway is endothelial nitric oxide. In preeclampsia (PE), maternal systemic and renal vasoconstriction leads to hypertension and modest reduction in GFR exceeding that of RPF. Elevated level of circulating soluble vascular endothelial growth factor receptor-1 arising from the placenta is implicated in the hypertension and disruption of glomerular fenestrae and barrier function, the former causing reduced Kf and the latter proteinuria. Additional pathogenic factors are discussed. Last, potential clinical ramifications include RLN replacement in women conceiving with donor eggs and its therapeutic use in PE. Another goal has been to apply knowledge gained from investigating circulatory adaptations in pregnancy toward identifying and developing novel therapeutic strategies for renal and cardiovascular disease in the nonpregnant population. So far, one candidate to emerge is RLN and its potential therapeutic use in heart failure.

Renal hemodynamics, electrolyte excretion and water metabolism in pregnant sheep before and after the induction of toxemia of pregnancy

Renal hemodynamics, electrolyte excretion and plasma level of glucorticoids were studied in pregnant sheep before and after the experimental induction of toxemia. Marked renal ischemia occurred in the animals which developed toxemia. This abnormality occurred concomitantly with an increase in plasma corticoids. Despite the renal ischemia, arterial pressure remained the same. There are some similarities between the toxemia of the sheep and that of human pregnancy.

[The experimental examination of the effect on the uterine blood flow of angiotensin II during pregnancy (author's transl)]

In experiments with animals it was investigated the endurance of the myometrial and the blood flow of the renal cortex during endogenous pressure substances. At the same time it was tested, if treatment with sexual hormones or a pregnancy had the tested principles and changes through pressure substances, and that the changes were significant. The investigations were conducted on three groups of female rabbits. The blood changes in myometrial and in the uterine were measured and continually registered with the special heated thermistor, from the principle of the thermoclearance. The success of the blood pressure was intraarterial measured with an electric mechanism. Precisely the same doses (in relativity of the animals weight) of pressure substances were applied with an infusions pump intravenously. And pressure substances Angiotensin II, Norepinephrine and Epinephrine, and their actions on the blood pressure and blood flow through the myometrium and through the renal cortex were examined. Altogether 131 values were registered. The results of the study that were statistically secure were as follows: a) The uterine blood flow pro tissue volume unit stays constant also by pregnancy or pseudopregnancy. b) The blood flow of the kidney is perhaps twice as high as the myometrial. c) The myometrial blood flow is with the arterial systolic blood pressure tightly correlated. Blood pressure increases through Angiotensin-infusion and also recovery of the uterine blood flow. d) An autoregulation of the uterine blood flow is not observed. e) The decrease of the renal blood flow after the giving of pressure substances was not modified through pregnancy. f) In quality the behaviour of the organ blood flow is the same after applied infusion of the pressure substances. Quantity differences exist however between Angiotensin II, Norepinephrine and Epinephrine. The method of measuring the blood flow through the uterus and in the kidney was placed in one view there. The finding of another examination groups for the problem of the organ blood flow in pregnancy was under critical consideration the methods combined and in connection with the proper examinations discussed. Till now in the theory over the cause of EPH-syndrom the predominate recently compiled comprehensive summary was; the proper body pressure substances--especially from the renin Angiotensin system--after chronical invoices it was decides diminished uterus blood flow appeared. After the earlier results were not all secure. The proper examination speech was therefore, that regarding the kidney function relevant alterations, also unter the conditions of pregnancy, are to be observed. The pressure dependant regulation of myometrial blood flow without proving autoregulation required however another test of the predominante gestose theory.

Ultrastructural studies in hypertension. IV. Toxemia of pregnancy

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