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Artan AS, Mirioglu S, Ünal E, Suleymanova V, Akin Oto O, Ozturk S, Yazici H, Saraç Sivrikoz T, Turkmen A. Maternal and neonatal outcomes in kidney transplant recipients: a single-center observational study. Wien Klin Wochenschr 2024:10.1007/s00508-024-02425-2. [PMID: 39231814 DOI: 10.1007/s00508-024-02425-2] [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: 04/04/2024] [Accepted: 07/29/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVE Pregnancy poses a high risk for adverse maternal and neonatal outcomes in kidney transplant recipients (KTRs), and data on long-term allograft functions compared to the healthy population are still limited. Therefore, we aimed to conduct a comparative analysis of maternal and neonatal outcomes in KTRs. SUBJECT AND METHODS In this retrospective single-center study, KTRs who experienced pregnancy after transplantation were evaluated in comparison with an age-matched non-transplanted control group. Maternal outcomes included obstetric complications (preeclampsia, peripartum hemorrhage, duration of maternal hospitalization) and a composite kidney outcome for KTRs defined as progression to graft failure necessitating dialysis or retransplantation or doubling of serum creatinine at the end of follow-up. Neonatal outcomes were gestational age, preterm birth, newborn mortality, admittance to the neonatal intensive care unit (NICU), Apgar scores, and birth weight. RESULTS In 53 KTRs, 68 pregnancies occurred. Preeclampsia (p < 0.001) and preterm birth (p = 0.003) were significantly higher in KTRs. The KTR pregnancies had lower mean birth weights (p = 0.001) and longer durations of maternal hospitalization (p = 0.001). Neonatal mortality, NICU admissions, peripartum hemorrhage rates, and Apgar scores were similar between groups. Follow-up for a median of 105 months after the index birth showed higher serum creatinine levels at postpartum visits (p < 0.001) and at the last follow-up (p = 0.001) compared to baseline. Of the KTRs 6 (11.3%) experienced composite kidney outcomes, including 5 patients with graft failure and 1 with a doubling of serum creatinine. CONCLUSION The KTRs exhibit comparable neonatal mortality and NICU admission rates but have higher rates of preeclampsia and preterm birth. Importantly, graft functions worsen significantly during postpartum follow-up.
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Affiliation(s)
- Ayse Serra Artan
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Safak Mirioglu
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Elif Ünal
- Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Vafa Suleymanova
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Savas Ozturk
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tuğba Saraç Sivrikoz
- Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Jee SB, Sawal A. Physiological Changes in Pregnant Women Due to Hormonal Changes. Cureus 2024; 16:e55544. [PMID: 38576690 PMCID: PMC10993087 DOI: 10.7759/cureus.55544] [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: 07/26/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
Pregnancy affects many organ systems and causes significant physiological changes that are mainly caused by changes in hormone levels. This review explores the complex interactions between pregnancy-related hormonal changes and renal function, providing insights into the practical applications of these relationships. Extensive literature searches were conducted, combining data from several sources to produce thorough knowledge. Essential discoveries include changes in renal hemodynamics, calcium/phosphorus level variations, thyroid gland hypertrophy, changed function, and cardiovascular adaptations. The review also addresses how sex hormones affect immunological responses, emphasizing their importance for conditions like multiple sclerosis. Additionally impacted is the gastrointestinal tract, which results in symptoms like nausea and heartburn. Comprehending these physiological changes is essential for proficient therapeutic handling, guaranteeing the best possible health for both the mother and the fetus. The study emphasizes the importance of specialized medical treatment during pregnancy and calls for more investigation to clarify the intricacies of these physiological changes.
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Affiliation(s)
- Sohan B Jee
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Sawangi (Meghe) Wardha, Wardha, IND
| | - Anupama Sawal
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Sawangi (Meghe) Wardha, Wardha, IND
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Wei L, Shen X, Zhang J, Yong Z, Zhang Q, Zhao W. Different equations for estimating age-related changes of glomerular filtration rate in the healthy population. BMC Nephrol 2023; 24:342. [PMID: 37978461 PMCID: PMC10657123 DOI: 10.1186/s12882-023-03397-7] [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] [Received: 05/15/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Identifying age-related trend of estimated glomerular filtration rate (eGFR) is necessary to assess whether kidney function is healthily aging. This study aimed to investigate the application of CKD-EPI, FAS, and Xiangya equations for the aging estimation of eGFR in the healthy Chinese individuals. METHODS A total of 36,911 healthy individuals were enrolled in this study. We grouped every ten years to observe the trend of eGFR with aging and investigated decline rate of it by general linear regression analysis in each age-groups. Agreement between equations was determined by intraclass correlation coefficient (ICC) and Bland-Altman plot. We calculated reference interval in each age-group. We further analyzed above statistical indicators in males and females. RESULTS The eGFR by CKD-EPI, and Xiangya equation started to decline from the age of 18. Whereas eGFR by FAS equation remained stable under 40 years, then decreased more rapidly. Compared with males, the females had a higher level but a faster decline rate of eGFR with aging. Agreement analysis revealed good agreement between CKD-EPI and FAS equations (ICC 0.818-0.920). Agreement between Xiangya and CKD-EPI or FAS equations was poor to moderate in most of the population under 70 years old (ICC 0.282-0.786), but good in individuals above 70 years (ICC 0.769-0.881). CONCLUSIONS The trend of eGFR with aging was different by CKD-EPI, FAS, and Xiangya equations in the healthy Chinese. It may be necessary to take these equations- or age-related differences into consideration when assessing kidney function in primary health care and clinical practice.
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Affiliation(s)
- Lu Wei
- Division of Nephrology, Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Xue Shen
- Division of Nephrology, Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Juan Zhang
- Division of Nephrology, Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Zhenzhu Yong
- Division of Nephrology, Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Qun Zhang
- Department of Health Management, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weihong Zhao
- Division of Nephrology, Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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Artan AS, Fleetwood V, Guller N, Oto OA, Mirioglu S, Yazici H, Turkmen A, Caliskan Y, Lentine KL. Pregnancy in Living Kidney Donors: An Evidence-Based Review. CURRENT TRANSPLANTATION REPORTS 2023; 10:110-116. [PMID: 37743976 PMCID: PMC10512453 DOI: 10.1007/s40472-023-00402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 09/26/2023]
Abstract
Purpose of review To review the current studies and guidelines on the risk of adverse pregnancy outcomes in female kidney donors. Recent findings Living kidney donors include a significant amount of young women of child-bearing age. Safety and possible risks of pregnancy after donation are a concern for female kidney donor candidates. Many current studies indicate a higher risk of preeclampsia in women after kidney donation. Considering the increasing number of living kidney donors, the maternal outcomes of living kidney donation is an active area of research. Summary Guidelines and consensus statements on the risk of pregnancy in living kidney donors recommend close monitoring of blood pressure, weight gain, and proteinuria during pregnancy. Current studies indicate an increased risk of hypertensive disorders of pregnancy in living kidney donors. Counseling and informing donor candidates about the possible risks is important.
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Affiliation(s)
- Ayse Serra Artan
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Vidyaratna Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Nurane Guller
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Safak Mirioglu
- Division of Nephrology, Department of Internal Medicine, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yasar Caliskan
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
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Kang J, Hwang S, Lee T, Ahn K, Seo DM, Choi SJ, Uh Y. Prediction Model for Pre-Eclampsia Using Gestational-Age-Specific Serum Creatinine Distribution. BIOLOGY 2023; 12:816. [PMID: 37372101 DOI: 10.3390/biology12060816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023]
Abstract
Pre-eclampsia (PE) is a pregnancy-related disease, causing significant threats to both mothers and babies. Numerous studies have identified the association between PE and renal dysfunction. However, in clinical practice, kidney problems in pregnant women are often overlooked due to physiologic adaptations during pregnancy, including renal hyperfiltration. Recent studies have reported serum creatinine (SCr) level distribution based on gestational age (GA) and demonstrated that deviations from the expected patterns can predict adverse pregnancy outcomes, including PE. This study aimed to establish a PE prediction model using expert knowledge and by considering renal physiologic adaptation during pregnancy. This retrospective study included pregnant women who delivered at the Wonju Severance Christian Hospital. Input variables, such as age, gestational weeks, chronic diseases, and SCr levels, were used to establish the PE prediction model. By integrating SCr, GA, GA-specific SCr distribution, and quartile groups of GA-specific SCr (GAQ) were made. To provide generalized performance, a random sampling method was used. As a result, GAQ improved the predictive performance for any cases of PE and triple cases, including PE, preterm birth, and fetal growth restriction. We propose a prediction model for PE consolidating readily available clinical blood test information and pregnancy-related renal physiologic adaptations.
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Affiliation(s)
- Jieun Kang
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sangwon Hwang
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Taesic Lee
- Division of Data-Mining and Computational Biology, Institute of Global Health Care and Development, Wonju 26426, Republic of Korea
- Department of Family Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Kwangjin Ahn
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Dong Min Seo
- Department of Medical Information, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Seong Jin Choi
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Young Uh
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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Chen N, Zeng R, Xu C, Lai F, Chen L, Wang C, Pei L, Li Z, Li Y, Xiao H, Cao X. Low Serum Creatinine Levels in Early Pregnancy Are Associated with a Higher Incidence of Postpartum Abnormal Glucose Metabolism among Women with Gestational Diabetes Mellitus: A Retrospective Cohort Study. Nutrients 2023; 15:2193. [PMID: 37432359 DOI: 10.3390/nu15092193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 07/12/2023] Open
Abstract
The predictive factors for the progression from gestational diabetes mellitus (GDM) to type 2 diabetes remain incompletely elucidated. Our objective was to investigate the link between serum creatinine, a proxy for skeletal muscle mass, and the development of postpartum abnormal glucose metabolism (AGM). METHODS A retrospective review of the medical records of 501 women with GDM was conducted, all of whom underwent a 75 g oral glucose tolerance test (OGTT) between 4 and 12 weeks postpartum. Women were grouped based on quartiles of serum creatinine at the first antenatal visit to estimate the association between serum creatinine and postpartum AGM incidence. RESULTS Compared with the highest quartile of creatinine, lower quartiles were substantially linked to an increased incidence of postpartum AGM (adjusted odds ratios 3.37 [95% CI 1.77-6.42], 2.42 [95% CI 1.29-4.51] and 2.27 [95% CI 1.23-4.18], respectively). The generalized additive model suggested a linear relationship between serum creatinine levels and the risk of postpartum AGM below 68 µmol/L of serum creatinine levels. A decrease of 2 μmol/L in serum creatinine levels was found to be associated with a 10% increase in the odds of developing postpartum AGM. Linear regression revealed that a low serum creatinine level was linked to a higher postpartum 2-h glucose level and a decreased insulinogenic index (p = 0.007 and p = 0.027, respectively). CONCLUSIONS An association was observed between lower serum creatinine levels in early pregnancy and an increased risk of postpartum AGM and poorer β-cell function in women with a recent history of GDM. Further research is needed to understand the mechanisms underlying our findings, as well as the role of skeletal muscle mass or nutritional status in early pregnancy on later glucose metabolism.
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Affiliation(s)
- Nan Chen
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Rui Zeng
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Changliu Xu
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Fenghua Lai
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Li Chen
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Chenxue Wang
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Ling Pei
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Zhuyu Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Yanbing Li
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Haipeng Xiao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
| | - Xiaopei Cao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou 510080, China
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Berlinska L, Marichereda V, Rohachevskyi O, Volyanska A, Lavrynenko G. The model of screening for preeclampsia in the second and third trimesters of gestation. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
<b>Purpose:</b> Preeclampsia (PE) is a specific syndrome of multiple organ insufficiency in case of pregnancy, which is included in the panel of major obstetric syndromes and is among the main causes of maternal morbidity and mortality in the whole world.<br />
<b>Material and methods</b>: We conducted a prospective cohort study of 91 pregnant women to evaluate the effectiveness of integrated use of maternal risk factors (2019 International Federation of Gynecology and Obstetrics recommendations), placenta location (ultrasound at 18-20 weeks of gestation), and serum cystatin C (at 18-36 weeks of gestation) in screening for pe in the second and third trimesters of gestation.<br />
<b>Results: </b>In the subgroup of pregnant women with cystatin C levels greater than 1.0 mg/L (27 women), PE developed in 26 women, which is 96.29% in percentage terms. When calculating GFR for cystatin C in a group with PE there was a significant violation of the renal filtration system -52.46±2.08 (95% CI, 48.39-56.54), while in healthy group the indicator is within normal limits -97.6±1.64 (95% CI, 94.38-100.82). In the analysis of the ratio of cystatin C levels more than 1.0 mg / l and the development of PE, a sensitivity of 98.46%, specificity of 100% and accuracy of 98.9%, p<0.001.<br />
<b>Conclusions: </b>The data show that the combined model of maternal factors, ultrasound of the placenta and serum cystatin C, is prognostically effective in pregnant women in the second and third trimesters of gestation and is a reliable marker for the development of pe.
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Affiliation(s)
- Liudmyla Berlinska
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Valerie Marichereda
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Oleksandr Rohachevskyi
- Department of Simulation Medical Technologies, Odessa National Medical University, Odesa, UKRAINE
| | - Alla Volyanska
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Ganna Lavrynenko
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
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Pregnancy after Kidney Transplantation-Impact of Functional Renal Reserve, Slope of eGFR before Pregnancy, and Intensity of Immunosuppression on Kidney Function and Maternal Health. J Clin Med 2023; 12:jcm12041545. [PMID: 36836080 PMCID: PMC9964361 DOI: 10.3390/jcm12041545] [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: 01/12/2023] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Women of childbearing age show increased fertility after kidney transplantation. Of concern, preeclampsia, preterm delivery, and allograft dysfunction contribute to maternal and perinatal morbidity and mortality. We performed a retrospective single-center study, including 40 women with post-transplant pregnancies after single or combined pancreas-kidney transplantation between 2003 and 2019. Outcomes of kidney function up to 24 months after the end of pregnancy were compared with a matched-pair cohort of 40 transplanted patients without pregnancies. With a maternal survival rate of 100%, 39 out of 46 pregnancies ended up with a live-born baby. The eGFR slopes to the end of 24 months follow-up showed mean eGFR declines in both groups (-5.4 ± 14.3 mL/min in pregnant versus -7.6 ± 14.1 mL/min in controls). We identified 18 women with adverse pregnancy events, defined as preeclampsia with severe end-organ dysfunction. An impaired hyperfiltration during pregnancy was a significant risk contributor for both adverse pregnancy events (p < 0.05) and deterioration of kidney function (p < 0.01). In addition, a declining renal allograft function in the year before pregnancy was a negative predictor of worsening allograft function after 24 months of follow-up. No increased frequency of de novo donor-specific antibodies after delivery could be detected. Overall, pregnancies in women after kidney transplantation showed good allograft and maternal outcomes.
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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10
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Piccoli GB, Chatrenet A, Cataldo M, Torreggiani M, Attini R, Masturzo B, Cabiddu G, Versino E. Adding creatinine to routine pregnancy tests: a decision tree for calculating the cost of identifying patients with CKD in pregnancy. Nephrol Dial Transplant 2023; 38:148-157. [PMID: 35238937 PMCID: PMC9869858 DOI: 10.1093/ndt/gfac051] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Even in its early stages, chronic kidney disease (CKD) is associated with adverse pregnancy outcomes. The current guidelines for pregnancy management suggest identifying risk factors for adverse outcomes but do not mention kidney diseases. Since CKD is often asymptomatic, pregnancy offers a valuable opportunity for diagnosis. The present analysis attempts to quantify the cost of adding serum creatinine to prenatal screening and monitoring tests. METHODS The decision tree we built takes several screening scenarios (before, during and after pregnancy) into consideration, following the hypothesis that while 1:750 pregnant women are affected by stage 4-5 CKD and 1:375 by stage 3B, only 50% of CKD cases are known. Prevalence of abortions/miscarriages was calculated at 30%; compliance with tests was hypothesized at 50% pre- and post-pregnancy and 90% during pregnancy (30% for miscarriages); the cost of serum creatinine (production cost) was set at 0.20 euros. A downloadable calculator, which makes it possible to adapt these figures to other settings, is available. RESULTS The cost per detected CKD case ranged from 111 euros (one test during pregnancy, diagnostic yield 64.8%) to 281.90 euros (one test per trimester, plus one post-pregnancy or miscarriage, diagnostic yield 87.7%). The best policy is identified as one test pre-, one during and one post-pregnancy (191.80 euros, diagnostic yield 89.4%). CONCLUSIONS This study suggests the feasibility of early CKD diagnosis in pregnancy by adding serum creatinine to routinely performed prenatal tests and offers cost estimates for further discussion.
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Affiliation(s)
| | - Antoine Chatrenet
- Néphrologie et dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, Le Mans, France
- Laboratory “Movement, Interactions, Performance” (EA 4334), Le Mans University, Le Mans, France
| | | | - Massimo Torreggiani
- Néphrologie et dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, Le Mans, France
| | - Rossella Attini
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, University of Torino, Turin, Italy
| | - Bianca Masturzo
- 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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11
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Agampodi SB, Agampodi TC, Amarasinghe GS, Warnasekara JN, Hettiarachchi AU, Jayasinghe IU, Koralegedara IS, Abeyrathna P, Srimantha S, de Silva FN, Gunarathne SP, Wickramasinghe ND. Serum creatinine and estimated glomerular filtration rate (eGFR) in early pregnancy and changes during the pregnancy. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000443. [PMID: 36962935 PMCID: PMC10021427 DOI: 10.1371/journal.pgph.0000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023]
Abstract
Renal functions in pregnancy undergo rapid changes, and the thresholds for normal values are a major research gap and are still debatable. The lack of prospective population-based studies with early pregnancy recruitment hampered the decision-making process on the best thresholds to be used in clinical practice. We present the serum creatinine (sCr) and sCr-based estimated glomerular filtration rates (eGFR) in early pregnancy with changes over the gestational period in a large prospective, community-based cohort, the Rajarata Pregnancy Cohort (RaPCo). We carried out a community-based prospective cohort study with 2,259 healthy pregnant women with a gestation period of less than 13 weeks and without pre-existing medical conditions. Gestational period-specific sCr and sCr-based eGFR were calculated for different age strata, and the participants were followed up until the second trimester. Renal functions of pregnant women were compared with 2.012 nonpregnant women from the same geographical area. The mean (SD) sCr of the 2,012 nonpregnant women was 62.8(12.4) μmol/L, with the 97.5th percentile of 89.0 μmol/L. Among the pregnant women, mean (SD) sCr was 55.1(8.3), 52.7(8.1), 51.1(9.1), 47.1(7.2), and 49.3 (9.9), while the 97.5th percentile for sCr was 72.4, 69.1, 70.0, 63.6, and 66.0 μmol/L respectively during the 4-7, 8-9, 10-12, 24-27 and 28-30 weeks of gestation. The average sCr value was 84.7% and 76.4% of the nonpregnant group, respectively, in the first and second trimesters. The mean eGFR was 123.4 (10.7) mL/min/1.73 m2 in the first trimester and increased up to 129.5 mL/min/1.73 m2 in the 24th week of gestation. The analysis of cohort data confirmed a significant reduction in sCr with advancing pregnancy (p<0 .001). This study provides thresholds for renal functions in pregnancy to be used in clinical practice. Clinical validation of the proposed thresholds needs to be evaluated with pregnancy and newborn outcomes.
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Affiliation(s)
- Suneth Buddhika Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Thilini Chanchala Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Gayani Shashikala Amarasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Janith Niwanthaka Warnasekara
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Ayesh Umeshana Hettiarachchi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Imasha Upulini Jayasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Iresha Sandamali Koralegedara
- Department of Anatomy, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Parami Abeyrathna
- Department of Family Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Shalka Srimantha
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Farika Nirmani de Silva
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Sajaan Praveena Gunarathne
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | - Nuwan Darshana Wickramasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
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12
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Gosselink ME, van Buren MC, Kooiman J, Groen H, Ganzevoort W, van Hamersvelt HW, van der Heijden OWH, van de Wetering J, Lely AT. A nationwide Dutch cohort study shows relatively good pregnancy outcomes after kidney transplantation and finds risk factors for adverse outcomes. Kidney Int 2022; 102:866-875. [PMID: 35777440 DOI: 10.1016/j.kint.2022.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/04/2022] [Accepted: 06/03/2022] [Indexed: 12/14/2022]
Abstract
Although numbers of pregnancy after kidney transplantation (KT) are rising, high risks of adverse pregnancy outcomes (APO) remain. Though important for pre-conception counselling and pregnancy monitoring, analyses of pregnancy outcomes after KT per pre-pregnancy estimated glomerular filtration rate-chronic kidney disease (eGFR-CKD)-categories have not been performed on a large scale before. To do this, we conducted a Dutch nationwide cohort study of consecutive singleton pregnancies over 20 weeks of gestation after KT. Outcomes were analyzed per pre-pregnancy eGFR-CKD category and a composite APO (cAPO) was established including birth weight under 2500 gram, preterm birth under 37 weeks, third trimester severe hypertension (systolic blood pressure over 160 and/or diastolic blood pressure over 110 mm Hg) and/or over 15% increase in serum creatinine during pregnancy. Risk factors for cAPO were analyzed in a multilevel model after multiple imputation of missing predictor values. In total, 288 pregnancies in 192 women were included. Total live birth was 93%, mean gestational age 35.6 weeks and mean birth weight 2383 gram. Independent risk factors for cAPO were pre-pregnancy eGFR, midterm percentage serum creatinine dip and midterm mean arterial pressure dip; odds ratio 0.98 (95% confidence interval 0.96-0.99), 0.95 (0.93-0.98) and 0.94 (0.90-0.98), respectively. The cAPO was a risk indicator for graft loss (hazard ratio 2.55, 1.09-5.96) but no significant risk factor on its own when considering pre-pregnancy eGFR (2.18, 0.92-5.13). This was the largest and most comprehensive study of pregnancy outcomes after KT, including pregnancies in women with poor kidney function, to facilitate individualized pre-pregnancy counselling based on pre-pregnancy graft function. Overall obstetric outcomes are good. The risk of adverse outcomes is mainly dependent on pre-pregnancy graft function and hemodynamic adaptation to pregnancy.
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Affiliation(s)
- Margriet E Gosselink
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Marleen C van Buren
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Judith Kooiman
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Henk W van Hamersvelt
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
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13
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Xie G, Wang R, Yang W, Sun L, Xu M, Zhang B, Yang L, Shang L, Qi C, Chung MC. Associations among prenatal PM 2.5, birth weight, and renal function. CHEMOSPHERE 2022; 301:134668. [PMID: 35460673 DOI: 10.1016/j.chemosphere.2022.134668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 04/02/2022] [Accepted: 04/18/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Low birth weight has long-term health effects, including neurodevelopmental delays, cardiovascular diseases, and type 2 diabetes, through epigenetic changes and modifications. Numerous studies have identified that PM2.5 is associated with low birth weight. However, the association between PM2.5 and renal function, as well as the mediated effect of renal function on the association between prenatal PM2.5 and birth weight are still under-recognized. METHODS A total of 8969 singleton live births born in 2015-2019 were included in this study. The inverse distance weighting method was applied to interpolate and calculate the average exposure to PM2.5 during pregnancy for each pregnant woman. The multiple linear regression model was used to shed light on the associations among prenatal PM2.5, birth weight, and renal function. In addition, the mediation analysis was performed to figure out the mediated effect of renal function on the association between prenatal PM2.5 and birth weight, and the proportion of mediated effect = (indirect effect/total effect) × 100%. RESULTS Per 10 μg/m3 increment of prenatal PM2.5 was associated with 8.98 g (95% CI: -16.94 to -1.02) decrease of birth weight, 0.49 (95% CI: -0.73 to -0.26) ml/min/1.73 m2 decrease of glomerular filtration rate (GFR), 0.03 (95% CI: 0.01-0.05) mmol/L increase of blood urea nitrogen (BUN), and 2.29 (95% CI: 0.86-3.72) μmol/L increase of uric acid (UA) after adjusting for the sociodemographic covariates, disease-related covariates and meteorological factors. Besides, the mediated effects of GFR and BUN on the association between prenatal PM2.5 and birth weight were 5.02% and 14.96%, but there was no significant mediated effect being identified in UA. CONCLUSION Prenatal PM2.5 is related to reduced birth weight and impaired renal function. Renal function plays a partial role in the association between prenatal PM2.5 and birth weight. Appropriate guidelines should be formulated by the concerned authorities, and adequate efforts should be made to mitigate the detrimental health effects of PM2.5.
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Affiliation(s)
- Guilan Xie
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Ruiqi Wang
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Wenfang Yang
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China.
| | - Landi Sun
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Mengmeng Xu
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Boxing Zhang
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Liren Yang
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Li Shang
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China; School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, People's Republic of China
| | - Cuifang Qi
- Department of Obstetrics and Gynecology, Maternal & Child Health Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Mei Chun Chung
- Division of Nutrition Epidemiology and Data Science, Friedman School of Nutrition Science and Policy, Tufts University, Massachusetts Boston, USA
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14
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Gestational age-specific serum creatinine can predict adverse pregnancy outcomes. Sci Rep 2022; 12:11224. [PMID: 35780246 PMCID: PMC9250531 DOI: 10.1038/s41598-022-15450-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
Serum creatinine level (SCr) typically decreases during pregnancy due to physiologic glomerular hyperfiltration. Therefore, the clinical practice of estimated glomerular filtration rate (eGFR) based on SCr concentrations might be inapplicable to pregnant women with kidney disease since it does not take into account of the pregnancy-related biological changes. We integrated the Wonju Severance Christian Hospital (WSCH)-based findings and prior knowledge from big data to reveal the relationship between the abnormal but hidden SCr level and adverse pregnancy outcomes. We analyzed 4004 pregnant women who visited in WSCH. Adverse pregnancy outcomes included preterm birth, preeclampsia, fetal growth retardation, and intrauterine fetal demise. We categorized the pregnant women into four groups based on the gestational age (GA)-unadjusted raw distribution (Q1–4raw), and then GA-specific (Q1–4adj) SCr distribution. Linear regression analysis revealed that Q1-4adj groups had better predictive outcomes than the Q1–4raw groups. In logistic regression model, the Q1–4adj groups exhibited a robust non-linear U-shaped relationship with the risk of adverse pregnancy outcomes, compared to the Q1–4raw groups. The integrative analysis on SCr with respect to GA-specific distribution could be used to screen out pregnant women with a normal SCr coupled with a decreased renal function.
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15
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van Buren MC, Gosselink M, Groen H, van Hamersvelt H, de Jong M, de Borst MH, Zietse R, van de Wetering J, Lely AT. Effect of Pregnancy on eGFR After Kidney Transplantation: A National Cohort Study. Transplantation 2022; 106:1262-1270. [PMID: 34456267 PMCID: PMC9128619 DOI: 10.1097/tp.0000000000003932] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effect of pregnancy on the course of estimated glomerular filtration rate (eGFR) is unknown in kidney transplant recipients (KTRs). METHODS We conducted a nationwide multicenter cohort study in KTRs with pregnancy (>20 wk) after kidney transplantation (KT). Annual eGFRs after KT until death or graft loss and additional eGFRs before each pregnancy were collected according to protocol. Changes in eGFR slope before and after each pregnancy were analyzed by generalized estimating equations multilevel analysis adjusted for transplant vintage. RESULTS We included 3194 eGFR measurements before and after pregnancy in 109 (55%) KTRs with 1, 78 (40%) with 2, and 10 (5%) with 3 pregnancies after KT. Median follow-up after first delivery post-KT was 14 y (interquartile range, 18 y). Adjusted mean eGFR prepregnancy was 59 mL/min/1.73 m2 (SEM [standard error of the mean] 1.72; 95% confidence interval [CI], 56-63), after the first pregnancy 56 mL/min/1.73 m2 (SEM 1.70; 95% CI, 53-60), after the second pregnancy 56 mL/min/1.73 m2 (SEM 2.19; 95% CI, 51-60), and after the third pregnancy 55 mL/min/1.73 m2 (SEM 8.63; 95% CI, 38-72). Overall eGFR slope after the first, second, and third pregnancies was not significantly worse than prepregnancy (P = 0.28). However, adjusted mean eGFR after the first pregnancy was 2.8 mL/min/1.73 m2 (P = 0.08) lower than prepregnancy. CONCLUSIONS The first pregnancy has a small, but insignificant, effect on eGFR slope in KTRs. Midterm hyperfiltration, a marker for renal reserve capacity, was associated with better eGFR and death-censored graft survival. In this KTR cohort with long-term follow-up, no significant effect of pregnancy on kidney function was detected.
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Affiliation(s)
- Marleen C. van Buren
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - Margriet Gosselink
- Department of Obstetrics, Wilhelmina Children’s Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, Groningen, The Netherlands
| | - Henk van Hamersvelt
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Margriet de Jong
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H. de Borst
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert Zietse
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - Jacqueline van de Wetering
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - A. Titia Lely
- Department of Obstetrics, Wilhelmina Children’s Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
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16
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Denic A, Rule AD, Gaillard F. Kidney glomerular filtration rate plasticity after transplantation. Clin Kidney J 2022; 15:841-844. [PMID: 35498905 PMCID: PMC9050537 DOI: 10.1093/ckj/sfab267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Indexed: 11/15/2022] Open
Abstract
Since the first living donor kidney transplantation about six decades ago, significant progress has been made in terms of extending allograft survival. However, to date, only a small number of studies have compared the functional changes of the donated kidney to that of the remaining kidney. Although relatively small, the study by Gonzalez Rinne et al. demonstrated the adaptive capacity of the transplanted kidney in 30 donor-recipient pairs. The glomerular filtration rate (GFR) in both donors and recipients was obtained 12 months after transplantation and the authors identified three scenarios: (i) where donors had a higher GFR than recipients; (ii) where donors had a lower GFR than recipients; and (iii) where donors had a similar GFR to recipients. The mechanisms mediating GFR adaptability after kidney transplantation seem to be associated with body surface area (including sex differences in body surface area). Microstructural analysis of human and animal models of renal physiology provides some clues to the physiological adaptation of the transplanted organ. The nephron number from endowment and age-related loss and the adaptive ability for compensatory glomerular hyperfiltration likely play a major role.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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17
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Zakaria ZZ, Al-Rumaihi S, Al-Absi RS, Farah H, Elamin M, Nader R, Bouabidi S, Suleiman SE, Nasr S, Al-Asmakh M. Physiological Changes and Interactions Between Microbiome and the Host During Pregnancy. Front Cell Infect Microbiol 2022; 12:824925. [PMID: 35265534 PMCID: PMC8899668 DOI: 10.3389/fcimb.2022.824925] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/26/2022] [Indexed: 12/20/2022] Open
Abstract
In recent years, it has become clear that microbiome play a variety of essential roles in human metabolism, immunity, and overall health and that the composition of these microbiome is influenced by our environment, diet, weight, hormones, and other factors. Indeed, numerous physiological and pathological conditions, including obesity and metabolic syndrome, are associated with changes in our microbiome, referred to as dysbiosis. As a result, it is not surprising that such changes occur during pregnancy, which includes substantial weight gain and significant changes in metabolism and immune defenses. The present review relates physiological changes during pregnancy to alterations in the microbial composition at various sites, including the gut, oral cavity, and vagina. Pregnancy has been linked to such microbial changes, and we believe that, in contrast to certain disease states, these microbial changes are vital for a healthy pregnancy, probably through their influence on the mother’s immunological, endocrinological, and metabolic status.
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Affiliation(s)
- Zain Zaki Zakaria
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
- Biomedical Research Center, Qatar University (QU), Doha, Qatar
| | - Shouq Al-Rumaihi
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Rana S. Al-Absi
- Department of Biological and Environmental Sciences, College of Arts and Sciences, Qatar University (QU), Doha, Qatar
| | - Huda Farah
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Muram Elamin
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Rahaf Nader
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Salma Bouabidi
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Sara Elgaili Suleiman
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Shahd Nasr
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
| | - Maha Al-Asmakh
- Department of Biomedical Sciences, College of Health Sciences, Qatar University (QU) Health, Qatar University, Doha, Qatar
- Biomedical Research Center, Qatar University (QU), Doha, Qatar
- *Correspondence: Maha Al-Asmakh,
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18
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Graft function and pregnancy outcomes after kidney transplantation. BMC Nephrol 2022; 23:27. [PMID: 35022021 PMCID: PMC8753888 DOI: 10.1186/s12882-022-02665-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background After kidney transplantation, pregnancy and graft function may have a reciprocal interaction. We evaluated the influence of graft function on the course of pregnancy and vice versa. Methods We performed a retrospective observational study of 92 pregnancies beyond the first trimester in 67 women after renal transplantation from 1972 to 2019. Pre-pregnancy eGFR was correlated with outcome parameters; graft function was evaluated by Kaplan Meier analysis. The course of graft function in 28 women who became pregnant after kidney transplantation with an eGFR of < 50 mL/min/1.73m2 was compared to a control group of 79 non-pregnant women after kidney transplantation during a comparable time period and with a matched basal graft function. Results Live births were 90.5% (fetal death n = 9). Maternal complications of pregnancy were preeclampsia 24% (graft loss 1, fetal death 3), graft rejection 5.4% (graft loss 1), hemolytic uremic syndrome 2% (graft loss 1, fetal death 1), maternal hemorrhage 2% (fetal death 1), urinary obstruction 10%, and cesarian section. (76%). Fetal complications were low gestational age (34.44 ± 5.02 weeks) and low birth weight (2322.26 ± 781.98 g). Mean pre-pregnancy eGFR was 59.39 ± 17.62 mL/min/1.73m2 (15% of cases < 40 mL/min/1.73m2). Pre-pregnancy eGFR correlated with gestation week at delivery (R = 0.393, p = 0.01) and with percent eGFR decline during pregnancy (R = 0.243, p = 0.04). Pregnancy-related eGFR decline was inversely correlated with the time from end of pregnancy to chronic graft failure or maternal death (R = -0.47, p = 0.001). Kaplan Meier curves comparing women with pre-pregnancy eGFR of ≥ 50 to < 50 mL/min showed a significantly longer post-pregnancy graft survival in the higher eGFR group (p = 0.04). Women after kidney transplantation who became pregnant with a low eGFR of > 25 to < 50 mL/min/1.73m2 had a marked decline of renal function compared to a matched non-pregnant control group (eGFR decline in percent of basal eGFR 19.34 ± 22.10%, n = 28, versus 2.61 ± 10.95%, n = 79, p < 0.0001). Conclusions After renal transplantation, pre-pregnancy graft function has a key role for pregnancy outcomes and graft function. In women with a low pre-pregnancy eGFR, pregnancy per se has a deleterious influence on graft function. Trial registration Since this was a retrospective observational case series and written consent of the patients was obtained for publication, according to our ethics’ board the analysis was exempt from IRB approval. Clinical Trial Registration was not done. The study protocol was approved by the Ethics Committee of Hannover Medical School, Chairman Prof. Dr. H. D. Troeger, Hannover, December 12, 2015 (IRB No. 2995–2015).
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19
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Bellos I, Pergialiotis V. Risk of pregnancy complications in living kidney donors: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 270:35-41. [PMID: 35016135 DOI: 10.1016/j.ejogrb.2021.12.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/26/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
Living kidney donation is associated with glomerular hyperfiltration, predisposing for the development of chronic kidney disease. The present meta-analysis aims to gather current evidence and clarify whether kidney donors are at increased risk of future pregnancy complications. Medline, Scopus, Web of Science, CENTRAL and Google Scholar were systematically searched from inception to August 29, 2021. Observational studies comparing the rates of adverse pregnancy outcomes among kidney donors and non-donors were selected. Random-effects models were fitted to provide meta-analysis estimates, while the quality of evidence was appraised with the Grading of Recommendations Assessment, Development and Evaluation approach. Five studies were included, comprising 430 donors and 23,540 non-donors. Living kidney donation was associated with significantly higher risk of preeclampsia (OR: 2.86, 95% CI: 1.62-5.05, moderate quality of evidence), gestational hypertension (OR: 2.53, 95% CI: 1.11-5.74, low quality of evidence) and preterm birth (OR: 1.32, 95% CI: 1.01-1.74, moderate quality of evidence). The anticipated absolute rates of preeclampsia, gestational hypertension and preterm birth were 7.4%, 5.4% and 8.3%, respectively. The risk of gestational diabetes, cesarean delivery, low birthweight and fetal death was similar between the two groups (low quality of evidence). In conclusion, women with history of kidney donation are at significantly increased risk of preeclampsia, gestational hypertension and preterm birth in subsequent pregnancies, although the absolute rate of complications remains below 10%. Future studies should confirm these effects and improve potential donor counseling by individualizing the risk of adverse perinatal outcomes.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece.
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece
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20
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Harel Z, Park AL, Ray JG. Association Between Blunted Glomerular Hyperfiltration in Pregnancy and Severe Maternal Morbidity-A Research Letter. Can J Kidney Health Dis 2021; 8:20543581211035221. [PMID: 34721883 PMCID: PMC8552384 DOI: 10.1177/20543581211035221] [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: 12/07/2020] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Glomerular hyperfiltration is one physiological adaptation to pregnancy, marked by a decline in serum creatinine (SCr) concentration by 16 weeks’ gestation. It is not known whether blunted glomerular hyperfiltration leads to adverse maternal outcomes, including severe maternal morbidity (SMM). Objective: To evaluate the association between blunted glomerular hyperfiltration and subsequent SMM or death. Design: Population-based cohort study Setting: Ontario, Canada, from 2008 to 2019. Participants: Included were births among women who had ≥ 1 SCr measured as an outpatient within 10 weeks before conception (“preconception”), and again, at 110/7 to 206/7 weeks’ gestation (“in-pregnancy”). Excluded were women who died before birth, who had end-stage renal disease or kidney transplantation before conception, or whose pre-pregnancy SCr was 125 μmol/L. Exposure: Net glomerular hyperfiltration defined as the preconception minus the in-pregnancy SCr. Measures: The primary study outcome was SMM or death arising from 23 weeks’ gestation up to 42 days after the index birth. Methods: Adjusted relative risks (aRRs) were calculated using Modified Poisson regression per 1-SD net blunting of glomerular hyperfiltration adjusting for important covariates. Results: A total of 10,323 births met all inclusion criteria. The mean (SD) SCr was 61.7 (11.0) μmol/L preconception, 48.0 (9.2) μmol/L in-pregnancy, and the mean net difference 13.6 (8.2) μmol/L. Among these births, the adjusted RR of SMM or death from 23 weeks’ gestation up to 42 days post-partum was 1.16 (95% confidence interval 1.14-1.30) per 1-SD (8.2 μmol/L) net blunting of glomerular hyperfiltration. Limitations: As SCr assessment is not a routine part of pregnancy care, its measurement could have been for a specific health condition thereby imparting selection bias. Conclusions: Blunted glomerular hyperfiltration in pregnancy may identify some women at higher risk of SMM. Further prospective research is needed about the implications of glomerular hyperfiltration in early pregnancy.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | | | - Joel G Ray
- ICES, Toronto, ON, Canada.,Departments of Medicine and Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON, Canada
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21
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 826] [Impact Index Per Article: 275.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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22
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Demyanova KA, Kozlovskaya NL, Korotchaeva YV, Apresyan SV, Rylceva LP, Usatenko GV, Lugovoj AO, Vorobyeva MA, Bondarenko TV, Bespalova AV, Volkova OA. Analysis of the course and outcomes of pregnancy in patients with advanced stages chronic kidney disease. TERAPEVT ARKH 2021; 93:685-692. [DOI: 10.26442/00403660.2021.06.200867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
Background. Pregnancy in patients with advanced chronic kidney disease (CKD) is associated with a high risk of adverse outcomes for the mother and the fetus, but data on the characteristics of the course of pregnancy in these women is limited.
Aim. To analyse of the course and outcomes of pregnancy in patients with CKD stages 3a4.
Materials and methods. Thirty five pregnant women with CKD stages 34 were included: 3a 12 (34.3%) patients, stage 3b 10 (28.6%), stage 4 13 (37.1%).
Results. Proteinuria, serum creatinine, blood pressure in dynamics, the presence of a physiological response were investigated. Pregnancy management included blood pressure correction, antianemic, antiplatelet, anticoagulant therapy, prevention and treatment of urinary infection, correction of metabolic disorders. All pregnant women had proteinuria of varying severity, which increased towards the end of pregnancy. Seventeen (51.5%) patients had hypertension, successfully corrected with antihypertensive drugs. The average delivery term was 34.6 weeks. Preeclampsia developed in 14 (42.4%) cases, an inverse relationship was found between the presence of a physiological response and preeclampsia (p=0.009; rs=-0.463). All children were born alive and viable. After delivery in patients with CKD 3a creatinine values returned to the pre-gestational level, in patients with grade 3b and 4 progression of CKD was noted.
Conclusion. A favorable pregnancy outcome in women with late stages of CKD is possible with constant monitoring by a multidisciplinary team of doctors with mandatory monitoring of renal function, proteinuria, blood pressure, coagulation, markers of preeclampsia and indicators of fetal health. It was proposed to consider the physiological response of the kidneys to pregnancy as a predictor of a favorable outcome.
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23
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Seah JM, Kam NM, Wong L, Tanner C, MacIsaac RJ, Shub A, Ekinci EI, Houlihan C. The association between maternal renal function and pregnancy outcomes in type 1 and type 2 diabetes. Diabetes Res Clin Pract 2020; 165:108225. [PMID: 32442556 DOI: 10.1016/j.diabres.2020.108225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/02/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
AIMS To investigate the prognostic value of estimated glomerular filtration rate (eGFR) and albuminuria in determining pregnancy outcomes in women with type 1 and type 2 diabetes. METHODS An observational study of pregnant women with type 1 (n = 92) and type 2 diabetes (n = 106) who delivered between 2004 and 2014 at a single tertiary obstetric centre. Clinical and biochemical characteristics were determined and related to major obstetric outcomes: preeclampsia, preterm birth <32 and <37 weeks, and neonatal intensive care admission. We used univariate analyses and multivariable logistic regression models with eGFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and albuminuria as covariates. RESULTS In the pooled diabetes cohort, multivariable logistic regression with eGFR and albuminuria status demonstrated that the presence of albuminuria (albumin-to-creatinine ratio ≥ 3.5 mg/mmol) (OR, 2.7; 95% CI, 1.42-4.99; P = 0.002) was associated with preeclampsia, whilst an eGFR of < 120 mL/min/1.73 m2 was associated with preterm birth < 32 weeks (OR, 1.04; 95% CI, 1.00-1.09; P = 0.02). CONCLUSIONS Despite its recognized limitations in pregnancy, lower eGFR values were associated with increased risk of adverse outcomes. Our exploratory data suggest eGFR, along with albuminuria, can aid in identifying women at high risk of developing adverse obstetric outcomes.
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Affiliation(s)
- Jas-Mine Seah
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Ning Mao Kam
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Lydia Wong
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Cara Tanner
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Street, Fitzroy, VIC 3065, Australia.
| | - Alexis Shub
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia.
| | - Elif I Ekinci
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia.
| | - Christine Houlihan
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia.
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24
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Harel Z, Park AL, Ray JG. Blunted Glomerular Hyperfiltration in Pregnancy and Risk of Adverse Perinatal Outcomes. Am J Kidney Dis 2020; 76:297-299. [PMID: 32387024 DOI: 10.1053/j.ajkd.2020.02.437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada.
| | | | - Joel G Ray
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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25
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Kumakura S, Okamoto K, Takeuchi S, Yoshida M, Nakamichi T, Nagasawa T, Fujikura E, Yamamoto T, Saito M, Hanita T, Satoh M, Sato H, Ito S, Harigae H, Miyazaki M. Kidney function, blood pressure and proteinuria were associated with pregnancy outcomes of pregnant women with chronic kidney disease: a single-center, retrospective study in the Asian population. Clin Exp Nephrol 2020; 24:547-556. [PMID: 32162117 DOI: 10.1007/s10157-020-01865-0] [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: 07/04/2019] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Studies among pregnant Asian women with chronic kidney disease (CKD) have not been widely performed; therefore, clinical criteria for these patients have not been well established. METHODS We conducted a retrospective study among pregnant women with CKD who received prenatal care at our institution for 8 consecutive years. Primary outcome was the development of severe adverse events (SAEs). We analyzed correlations between primary outcome and CKD parameters [age, body mass index (BMI), estimated glomerular filtration rate (eGFR), urinary protein-creatinine ratio (UP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and not normal blood pressure (non-NBP)] at the time of referral. Secondary outcomes were low birth weight (LBW), preterm delivery (PreD), and small for gestational age (SGA). We divided into two categories, CKD stage G1, and G2 or higher according to eGFR, and proteinuria negative and proteinuria positive according to UP, respectively. RESULTS We observed 89 pregnancies. SAE was observed in 28 pregnancies. In live birth cases, there were 28 PreD, 28 LBW and 13 SGA. Major SAEs included preeclampsia, superimposed preeclampsia, unscheduled cesarean section, neonatal intensive care unit admission, and fetal death. Stepwise logistic regression analysis selected eGFR (OR = 0.847, p = 0.026), SBP (OR = 1.897, p = 0.006) and proteinuria positive (OR = 2.96, p = 0.046) as the significant predictors of SAEs. There were no significant differences among the baseline characteristics stratified by SGA. CONCLUSIONS This is the first study to report pregnancy outcomes among Japanese non-disease-oriented patients with CKD. In Asians, especially in the Japanese population, kidney function, blood pressure and proteinuria might affect pregnancy outcomes.
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Affiliation(s)
- Satoshi Kumakura
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Division of Blood Purification, Tohoku University Hospital, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Koji Okamoto
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Saeko Takeuchi
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Mai Yoshida
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takashi Nakamichi
- Department of Nephrology, Ishinomaki Red-Cross Hospital, 71 Hebita-Aza-Nishinomichishita, Ishinomaki, Miyagi, 986-8255, Japan
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Emi Fujikura
- Division of Blood Purification, Tohoku University Hospital, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tae Yamamoto
- Department of Internal Medicine, Sendai City Hospital, 1-1-1 Asuto-Nagamachi, Aoba-ku, Sendai, Miyagi, 980-8502, Japan
| | - Masatoshi Saito
- Department of Gynecology and Obstetrics, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takushi Hanita
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Michihiro Satoh
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, 983-8536, Japan
| | - Hiroshi Sato
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Department of Internal Medicine, JR Sendai Hospital, 1-1-5 Itsutsubashi, Aoba-ku, Sendai, Miyagi, 980-0022, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Department of Medicine, Katta General Hospital, 36 Fukuokakuramoto-Aza-Shimookibara, Shiroishi, Miyagi, 989-0231, Japan
| | - Hideo Harigae
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,Division of Blood Purification, Tohoku University Hospital, 1-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
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26
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Kreepala C, Srila-On A, Kitporntheranunt M, Anakkamatee W, Lawtongkum P, Wattanavaekin K. The Association Between GFR Evaluated by Serum Cystatin C and Proteinuria During Pregnancy. Kidney Int Rep 2019; 4:854-863. [PMID: 31194092 PMCID: PMC6551540 DOI: 10.1016/j.ekir.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/05/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Physiological changes in pregnancy result in increased cardiac output and renal blood flow, with a consequential increase in proteinuria. Data from studies of the relationship between proteinuria caused by isolated proteinuria and glomerular filtration rate (GFR) are still limited. The objective of this study was to investigate the effects of isolated proteinuria on the cystatin C–based GFR in the third trimester of pregnancy. Methods Data were collected from pregnant women in their third trimester whose serum creatinine levels were normal. The GFR of each participant was measured using serum cystatin C levels, and proteinuria was measured using urine protein–creatinine ratios. The participants were divided into 3 groups according to their level of proteinuria: normal (<150 mg/d), physiological (150–300 mg/d), and gestational (>300 mg/d). Changes in GFR were recorded for each group. Results The study included 89 participants, of whom 66.3% had levels of proteinuria that did not differ from that of the normal population (<150 mg/d). The incidence of physiological and gestational proteinuria was 21.4% and 12.4%, respectively. The results demonstrate that proteinuria >101.50 mg/d was significantly associated with declined estimated glomerular filtration rate (eGFR) (r = –0.34, P = 0.01). The analysis found that proteinuria >491.27 mg/d led to a risk of GFR <90 ml/min with an odds ratio of 12.69, P = 0.02 when adjusted for systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index. Conclusion This study suggests that the term “physiological proteinuria” is a misnomer. When used in the traditional manner, creatinine level has inadequate sensitivity to estimate GFR in pregnant women. We found that there is a significant decline in GFR when urine protein > 101.5 mg/d, which could be an early biomarker for renal pathology rather than pregnancy physiology, suggesting that further workup and precaution is required.
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Affiliation(s)
- Chatchai Kreepala
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
| | - Atitaya Srila-On
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
| | - Maethaphan Kitporntheranunt
- Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
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27
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Harel Z, McArthur E, Hladunewich M, Dirk JS, Wald R, Garg AX, Ray JG. Serum Creatinine Levels Before, During, and After Pregnancy. JAMA 2019; 321:205-207. [PMID: 30644975 PMCID: PMC6439761 DOI: 10.1001/jama.2018.17948] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study uses Canadian administrative health databases to estimate gestational age–specific serum creatinine levels before, during, and after pregnancy among women without antecedent kidney disease.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michelle Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jade S. Dirk
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ron Wald
- Division of Nephrology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Amit X. Garg
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Joel G. Ray
- Department of Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
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28
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Yoo KD, Lee H, Kim Y, Park S, Park JS, Hong JS, Jeong CW, Kim HH, Lee JP, Kim DK, Oh KH, Joo KW, Kim YS. Maternal and fetal outcomes of pregnancies in kidney donors: A 30-year comparative analysis of matched non-donors in a single center. Kidney Res Clin Pract 2018; 37:356-365. [PMID: 30619691 PMCID: PMC6312783 DOI: 10.23876/j.krcp.18.0050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/24/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022] Open
Abstract
Background Woman kidney donors face obstetric complication risks after kidney donation, such as gestational hypertension and preeclampsia. Studies on childbirth-related complications among Asian women donors are scarce. Methods This retrospective cohort study included woman donors aged 45 years or younger at the time of kidney donation in a single tertiary hospital between 1985 and 2014. Pregnancy associated complications were investigated using medical records and telephone questionnaires for 426 pregnancies among 225 donors. Matched non-donor controls were selected by propensity score and the maternal and fetal outcomes were compared with those of donors. Primary outcomes were differences in maternal complications, and secondary outcomes were fetal outcomes in pregnancies of the donor and control groups. Results A total of 56 cases had post-donation pregnancies. The post-donation pregnancies group was younger at the time of donation and older at the time of delivery than the pre-donation pregnancies group, and there were no differences in primary outcomes between the groups except the proportion receiving cesarean section. Comparison of the complication risk between post-donation pregnancies and non-donor matched controls showed no significant differences in gestational hypertension, preeclampsia, or composite outcomes after propensity score matching including age at delivery, era at pregnancy, systolic blood pressure, body weight, and estimated glomerular filtration ratio (odds ratio, 0.63; 95% confidence interval, 0.19–2.14; P = 0.724). Conclusion This study revealed that maternal and fetal outcomes between woman kidney donors and non-donor matched controls were comparable. Studies with general population pregnancy controls are warranted to compare pregnancy outcomes for donors.
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Affiliation(s)
- Kyung Don Yoo
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yaerim Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sehoon Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Joon Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Hoe Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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29
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Lee H. Cystatin C in pregnant women is not a simple kidney filtration marker. Kidney Res Clin Pract 2018; 37:313-314. [PMID: 30619686 PMCID: PMC6312774 DOI: 10.23876/j.krcp.18.0146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul,
Korea
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30
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van Londen M, Schaeffers AWMA, de Borst MH, Joles JA, Navis G, Lely AT. Overweight young female kidney donors have low renal functional reserve postdonation. Am J Physiol Renal Physiol 2018; 315:F454-F459. [PMID: 29357424 DOI: 10.1152/ajprenal.00492.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Maintenance of adequate renal function after living kidney donation is important for donor outcome. Overweight donors, in particular, may have an increased risk for end-stage kidney disease (ESKD), and young female donors have an increased preeclampsia risk. Both of these risks may be associated with low postdonation renal functional reserve (RFR). Because we previously found that higher body mass index (BMI) was associated with lower postdonation RFR, we now studied the relationship between BMI and RFR in young female donors. RFR, the rise in glomerular filtration rate (GFR) (125I-iothalamate clearance) during dopamine, was measured in female donors (<45 yr) before and after kidney donation. Donors who are overweight (BMI >25) and nonoverweight donors were compared by Student's t-test; the association was subsequently explored with regression analysis. We included 105 female donors [age 41 (36-44) median(IQR)] with a BMI of 25 (22-27) kg/m2. Predonation GFR was 118 (17) ml/min [mean(SD)] rising to 128 (19) ml/min during dopamine; mean RFR was 10 (10) ml/min. Postdonation GFR was 76 (13) ml/min, rising to 80 (12); RFR was 4 (6) ml/min ( P < 0.001 vs. predonation). In overweight donors, RFR was fully lost after donation (1 ml/min vs. 10 ml/min predonation, P < 0.001), and BMI was inversely associated with RFR after donation, independent of confounders (standardized β 0.37, P = 0.02). Reduced RFR might associate with the risk of preeclampsia and ESKD in kidney donors. Prospective studies should explore whether RFR is related to preeclampsia and whether BMI reduction before conception is of benefit to overweight female kidney donors during and after pregnancy.
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Affiliation(s)
- Marco van Londen
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Anouk W M A Schaeffers
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynecology, Division of Women and Baby, University Medical Center Utrecht , Utrecht , The Netherlands
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31
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Tangren JS, Wan Md Adnan WAH, Powe CE, Ecker J, Bramham K, Hladunewich MA, Ankers E, Karumanchi SA, Thadhani R. Risk of Preeclampsia and Pregnancy Complications in Women With a History of Acute Kidney Injury. Hypertension 2018; 72:451-459. [PMID: 29915020 DOI: 10.1161/hypertensionaha.118.11161] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/30/2018] [Accepted: 05/21/2018] [Indexed: 12/12/2022]
Abstract
An episode of clinically recovered acute kidney injury (r-AKI) has been identified as a risk factor for future hypertension and cardiovascular disease. Our objective was to assess whether r-AKI was associated with future preeclampsia and other adverse pregnancy outcomes and to identify whether severity of AKI or time interval between AKI and pregnancy was associated with pregnancy complications. We conducted a retrospective cohort study of women who delivered infants between 1998 and 2016 at Massachusetts General Hospital. AKI was defined using the 2012 Kidney Disease Improving Global Outcomes laboratory criteria with subsequent clinical recovery (estimate glomerular filtration rate, >90 mL/min per 1.73 m2 before conception). AKI was further classified by severity (Kidney Disease Improving Global Outcomes stages 1-3) and time interval between AKI episode and the start of pregnancy. Women with r-AKI had an increased rate of preeclampsia compared with women without previous r-AKI (22% versus 9%; P<0.001). Infants of women with r-AKI were born earlier (gestational age, 38.2±3.0 versus 39.0±2.2 weeks; P<0.001) and were more likely to be small for gestational age (9% versus 5%; P=0.002). Increasing severity of r-AKI was associated with increased risk of preeclampsia for stages 2 and 3 AKI (adjusted odds ratio, 3.5; 95% confidence interval, 2.1-5.7 and adjusted odds ratio, 6.5; 95% confidence interval, 3.5-12.0, respectively), but not for stage 1 (adjusted odds ratio, 1.7; 95% confidence interval, 0.9-3.2). A history of AKI before pregnancy, despite apparent full recovery, was associated with increased risk of pregnancy complications. Severity and timing of the AKI episode modified the risk.
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Affiliation(s)
- Jessica Sheehan Tangren
- From the Division of Nephrology, Department of Medicine (J.S.T., E.A., R.T.)
- Harvard Medical School Boston, MA (J.S.T., C.E.P., J.E., S.A.K., R.T.)
| | - Wan Ahmad Hafiz Wan Md Adnan
- Massachusetts General Hospital, Boston; Nephrology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (W.A.H.W.M.A.)
| | - Camille E Powe
- Diabetes Unit, Division of Endocrinology, Department of Medicine (C.E.P.)
- Harvard Medical School Boston, MA (J.S.T., C.E.P., J.E., S.A.K., R.T.)
| | - Jeffrey Ecker
- Department of Obstetrics and Gynecology (J.E.)
- Harvard Medical School Boston, MA (J.S.T., C.E.P., J.E., S.A.K., R.T.)
| | - Kate Bramham
- Department of Renal Medicine, King's College London and King's Health Partners, London, United Kingdom (K.B.)
| | - Michelle A Hladunewich
- Massachusetts General Hospital, Boston; Nephrology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (W.A.H.W.M.A.)
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.A.H.)
| | - Elizabeth Ankers
- From the Division of Nephrology, Department of Medicine (J.S.T., E.A., R.T.)
| | - S Ananth Karumanchi
- Department of Medicine and Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical (S.A.K.)
- Harvard Medical School Boston, MA (J.S.T., C.E.P., J.E., S.A.K., R.T.)
- Department of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA (S.A.K., R.T.)
| | - Ravi Thadhani
- From the Division of Nephrology, Department of Medicine (J.S.T., E.A., R.T.)
- Harvard Medical School Boston, MA (J.S.T., C.E.P., J.E., S.A.K., R.T.)
- Department of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA (S.A.K., R.T.)
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32
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado; and
- Department of Medicine, Division of Nephrology and
- Department of Physiology, University of Toronto, Ontario, Canada
| | - David Z.I. Cherney
- Department of Medicine, Division of Nephrology and
- Department of Physiology, University of Toronto, Ontario, Canada
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