1
|
Gholizadeh Ghozloujeh Z, Singh T, Jhaveri KD, Shah S, Lerma E, Abdipour A, Norouzi S. Lupus nephritis: management challenges during pregnancy. FRONTIERS IN NEPHROLOGY 2024; 4:1390783. [PMID: 38895665 PMCID: PMC11183321 DOI: 10.3389/fneph.2024.1390783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.
Collapse
Affiliation(s)
- Zohreh Gholizadeh Ghozloujeh
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, United States
| | - Silvi Shah
- Department of Medicine, Division of Nephrology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Edgar Lerma
- Department of Medicine, Division of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, United States
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| |
Collapse
|
2
|
Tripathi PU, Patvekar MM, Suryarao P, Ghotankar SS. In Vitro Fertilisation and Systemic Lupus Erythematosus: Making The Correct Choice. Cureus 2024; 16:e60100. [PMID: 38860088 PMCID: PMC11164295 DOI: 10.7759/cureus.60100] [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: 04/09/2024] [Accepted: 05/11/2024] [Indexed: 06/12/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that increases the risk of complications in pregnancy. SLE flares during pregnancy are attributed to higher levels of estrogen and other cytokines. A 34-year-old woman with SLE, who had undergone in vitro fertilization (IVF), was diagnosed with a lupus flare at 14 weeks of gestation. Prior to conception, it is essential to evaluate disease activity, major organ complications, hypercoagulability, and any other medical conditions that could affect pregnancy outcomes in women with SLE in order to prevent adverse results. Additionally, the presence of anti-phospholipid antibodies (APLA) should be ruled out before considering assisted reproductive techniques (ART). After conception, optimal and vigilant monitoring is essential. A multidisciplinary team and approach should be employed throughout pregnancy to manage disease progression and identify any further complications. In conclusion, effective counseling and clear explanations of risks and benefits are pivotal in empowering the patient to make an informed decision.
Collapse
Affiliation(s)
- Pankti U Tripathi
- Obstetrics and Gynaecology, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Meenal M Patvekar
- Obstetrics and Gynaecology, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Prashant Suryarao
- Obstetrics and Gynaecology, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Shambhavi S Ghotankar
- Central Research Facility, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, IND
| |
Collapse
|
3
|
Piccoli GB, Attini R, Torreggiani M, Chatrenet A, Manzione AM, Masturzo B, Casula V, Longhitano E, Dalmasso E, Biancone L, Pani A, Cabiddu G. Any reduction in maternal kidney mass makes a difference during pregnancy in gestational and fetal outcome. Kidney Int 2024; 105:865-876. [PMID: 38296027 DOI: 10.1016/j.kint.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 11/29/2023] [Accepted: 12/15/2023] [Indexed: 02/19/2024]
Abstract
Little is known about the effect tubulointerstitial nephropathies have in modulating maternal-fetal outcomes in pregnancy. Therefore, we analyzed the main outcomes of pregnancy in these women to gain a better understanding of the role of a reduction in maternal kidney mass. From the Torino Cagliari Observational Study (TOCOS) cohort, we selected 529 patients with a diagnosis of tubulointerstitial disease and focused on 421 patients with chronic kidney disease (CKD) stage 1, without hypertension but with proteinuria less than 0.5 g/day at referral. From a cohort of 2969 singleton deliveries from low-risk pregnancies followed in the same settings we selected a propensity score matched control cohort of 842 pregnancies match 2:1 for age, parity, body mass index, ethnicity, and origin. Time to delivery was significantly shorter in the study cohort 38.0 (Quartile 1-Quartile 3: 37.0-39.0) versus 39.0 (Q1-Q3 38.0-40.0) weeks, with respect to controls. Incidence of delivery of less than 37 gestational weeks significantly increased from controls (7.4%) to women with previous acute pyelonephritis (10.8%), other tubulointerstitial diseases (9.7%) and was the highest in patients with a single kidney (31.1%). Similarly, neonatal birthweight significantly and progressively decreased from controls (3260 g [Q1-Q3: 2980-3530]), previous acute pyelonephritis (3090 g [Q1-Q3: 2868-3405], other tubulointerstitial diseases (3110 g [Q1-Q3: 2840-3417]), and to solitary kidney (2910 g [Q1-Q3: 2480-3240]). Risk of developing preeclampsia was significantly higher in the CKD cohort (3.6% vs 1.7% in low-risk controls). Thus, even a small reduction in functional kidney mass, such as a pyelonephritic scar, is associated with a shorter duration of pregnancy and an increased risk of preterm delivery. The risk is proportional to the extent of parenchymal reduction and is highest in cases with a solitary kidney.
Collapse
Affiliation(s)
| | - Rossella Attini
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | | | - Antoine Chatrenet
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; APCoSS-Institute of Physical Education and Sports Sciences (IFEPSA), UCO Angers, Angers, France
| | - Ana Maria Manzione
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Bianca Masturzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Viola Casula
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | - Elisa Longhitano
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. "G. Martino", University of Messina, Messina, Italy
| | - Eleonora Dalmasso
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Luigi Biancone
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Antonello Pani
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | - Gianfranca Cabiddu
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| |
Collapse
|
4
|
Jiang Y, Tao M, Chen J, Luo L, You Q, Wu H, Zhang N. Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety. Eur J Obstet Gynecol Reprod Biol 2024; 294:148-155. [PMID: 38245953 DOI: 10.1016/j.ejogrb.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.
Collapse
Affiliation(s)
- Yi Jiang
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Min Tao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Jingjing Chen
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Lihua Luo
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Qingxia You
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Hong Wu
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Nian Zhang
- Department of Traditional Chinese Medicine, The Second Hospital Affiliated to Army Medical University, Chongqing 400037, China.
| |
Collapse
|
5
|
Çetin Ç, Saraç-Sivrikoz T, Ateş-Tıkız M, Zaralı S, Ersoy A, Yalçınkaya Y, Gül A, İnanç M, Has R, Kalelioğlu İ, Artım Esen B. The correlation between pregnancy, disease activity and adverse pregnancy outcomes in patients with systemic lupus erythematosus. Lupus 2023; 32:1509-1517. [PMID: 37855206 DOI: 10.1177/09612033231208844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVE In this study, our pregnant systemic lupus erythematosus (SLE) cohort, which was under medical surveillance of both our Rheumatology and Obstetrics departments, was analyzed. We intended to determine the effects of pregnancy on disease activity and the correlation between disease flares and adverse pregnancy outcomes. METHODS One hundred sixty eight pregnancy data involving 136 patients with SLE were examined. Cumulative clinical, laboratory, and serological parameters were described. Disease activity and flares were calculated using the systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) in the pre/postpartum periods and the SLEPDAI in the three trimesters of pregnancy. Patients with a SLEDAI-2K or SLEPDAI ≥ 4 were classified as "active." Patients with lupus low disease activity state (LLDAS) during each of these periods were identified.Fetal/neonatal death, premature birth due to pre-eclampsia, eclampsia or hemolysis, elevated Liver enzymes (HELLP) syndrome, and neonates small for gestational age were determined as adverse pregnancy outcomes (APO). RESULTS Out of 168 pregnancies, there were 60 (35.7%) pregnancies with flares covering the pregnancy and 6 months of postpartum period. The mean SLEDAI in the 6 months postpartum period was significantly higher compared to mean disease activity during pregnancy (p < .05). Of all pregnancies, 132 (78.6%) were in LLDAS during pregnancy. Comparison of the frequency of severe postpartum flares in patients who were in LLDAS during pregnancy revealed a lower percentage of flares compared to those who were not in the LLDAS group (11 vs 29%, p < .05). APO was observed in 33.9% of 168 pregnancies. The mean SLEPDAI score was significantly higher in APO+ pregnancies than in APO- pregnancies (4.9 ± 6.1 vs 2.8 ± 4.9, p = .002). Comparison of SLICC damage score between APO - and + pregnancies revealed a significantly higher score in APO+ pregnancies (1.8 ± 2.1 vs 0.8 ± 1.3, p = .001). CONCLUSION Postpartum six-month period appears to have the highest risk for disease flares during SLE pregnancies. Disease activity during pregnancy increases the risk of APO. In order to achieve a positive pregnancy outcome and lower maternal morbidity, regular follow-up of patients is necessary.
Collapse
Affiliation(s)
- Çiğdem Çetin
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tuğba Saraç-Sivrikoz
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Müge Ateş-Tıkız
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sibel Zaralı
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayşenur Ersoy
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Yalçınkaya
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat İnanç
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Recep Has
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - İbrahim Kalelioğlu
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahar Artım Esen
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| |
Collapse
|
6
|
El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, El Gaafary M, Sarhan E, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Eissa M, Tabra SAA, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.
Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.
Collapse
|
7
|
Chen Y, Li K, Zhang H, Liu Z, Chen D, Yang L, Hu W. Good pregnancy outcomes in lupus nephritis patients with complete renal remission. Nephrol Dial Transplant 2021; 37:1888-1894. [PMID: 34610132 DOI: 10.1093/ndt/gfab289] [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: 06/15/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To investigate pregnancy outcomes and risk factors in patients with lupus nephritis (LN). METHODS A total of 158 pregnancies in 155 women with LN were divided into a remission group and a control group according to whether they achieved complete renal remission (CRR) prior to pregnancy. The adverse pregnancy outcomes and risk factors were retrospectively analyzed. RESULTS In the remission group, 130 LN patients with 133 pregnancies (two twin pregnancies) delivered 127 live births; 25 LN patients with 25 pregnancies delivered 19 live births in the control group. Compared with the control group, the remission group had significantly lower incidence of LN relapse, fetal loss, and premature birth. For LN patients in the remission group, a CRR duration < 18 months (odds ratio (OR) 11.24, 95% confidence interval (CI) 2.95-42.80, P < 0.001) and anti-C1q antibody positivity before pregnancy (OR 7.2, 95% CI 1.38-37.41, P = 0.019) were independent risk factors for LN relapse; anti-phospholipid antibody positivity (OR 9.32, 95% CI 1.27-68.27, P = 0.028) and prednisone dosage during pregnancy ≥ 12.5 mg/d (OR 3.88, 95% CI 1.37-10.99, P = 0.011) were independent risk factors for fetal loss and premature birth, respectively; and age > 30 years was an independent risk factor for preeclampsia and premature birth. CONCLUSION LN patients with a complete renal remission duration greater than 18 months were associated with good pregnancy outcomes and lower LN relapse. Age, anti-C1q and anti-phospholipid antibodies, and prednisone dosage during pregnancy were risk factors for adverse pregnancy outcomes.
Collapse
Affiliation(s)
- Yinghua Chen
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | | | - Haitao Zhang
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Zhengzhao Liu
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Duqun Chen
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Liu Yang
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Weixin Hu
- National Clinical Research Centre for Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China.,The First School of Clinical Medicine, Southern Medical University, China
| |
Collapse
|
8
|
Limesh M, Kedlaya PG, Renuka S, Vinod N. Long-term Outcome of Lupus Nephritis: A Single Center Study. Indian J Nephrol 2021; 31:225-229. [PMID: 34376934 PMCID: PMC8330641 DOI: 10.4103/ijn.ijn_25_20] [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: 01/18/2020] [Revised: 04/13/2020] [Accepted: 05/06/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction There is paucity of data on long-term outcome of lupus nephritis (LN) from south India. Our study looks at long term outcomes in patients with biopsy proven LN with terms of response to therapy, flare, mortality, treatment-related complications, outcome and post flare analysis. We also analyzed the factors which predicted the outcome. Methods A retrospective observational study was conducted from 2005 to 2012 at St. John's Medical college and hospital, Bangalore. Patients received treatment as per NIH protocol. Patients of LN who regularly visited OPD were included. Statistical analysis was done by using SPSS 19 software. Results At end of 84 ± 6 months (N = 59), 38 subjects showed complete remission (CR), 6 partial remission (PR), 3 developed chronic kidney disease, 2 developed end-stage kidney disease (ESKD), and 10 died. In outcome of flare (N = 15), 7 had nephrotic flare, 3 had refractory flare, 3 showed nephritic flare with 2 developing ESKD. Change of LN class was 3 subjects had changed to class II from class IV, 1 to class II from class V, 7 to class III from class IV, 2 to class IV from class V, and 2 to class IV from class VI. Factors predicting poor outcomes were serum creatinine, hypertension at presentation, and failure to achieve remission in 1 year. 7 subjects conceived, of which 4 of them were treated with azathioprine (AZA) and 3 of them who were on mycophenolate mofetil and was changed to AZA. 4 subjects had successful pregnancy outcome, 2 had preeclampsia, and 1 subject had missed abortion. Conclusion At end of 84 ± 6 months, patient survival rate was 84%.
Collapse
Affiliation(s)
- M Limesh
- Department of Nephrology, St. Johns Medical College, Bangalore, Karnataka, India
| | - Prashanth G Kedlaya
- Department of Nephrology, St. Johns Medical College, Bangalore, Karnataka, India
| | - S Renuka
- Department of Nephrology, St. Johns Medical College, Bangalore, Karnataka, India
| | - N Vinod
- Department of Nephrology, St. Johns Medical College, Bangalore, Karnataka, India
| |
Collapse
|
9
|
Aguirre A, Urisman A, Margaretten M. Starting off on the right foot: A 22-year-old woman with leg swelling. Arthritis Care Res (Hoboken) 2021; 74:701-708. [PMID: 34197038 DOI: 10.1002/acr.24738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 11/08/2022]
Abstract
A previously healthy 22-year-old woman was in the second trimester of her first pregnancy when she developed new lower extremity edema. Her pregnancy course had been unremarkable, and she was receiving routine obstetric care from her family physician. One week prior to admission she developed progressive swelling in her legs.
Collapse
Affiliation(s)
- Alfredo Aguirre
- University of California, San Francisco, Department of Medicine, Division of Rheumatology
| | - Anatoly Urisman
- University of California, San Francisco, Department of Pathology
| | - Mary Margaretten
- University of California, San Francisco, Department of Medicine, Division of Rheumatology
| |
Collapse
|
10
|
Pregnancy outcomes in patients with systemic lupus erythematosus with or without a history of lupus nephritis. Clin Exp Nephrol 2021; 25:835-843. [PMID: 34165663 DOI: 10.1007/s10157-020-02017-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/28/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pregnancy is an important issue for many women with systemic lupus erythematosus (SLE). This study examined maternal and fetal outcomes among SLE women with or without a history of lupus nephritis (LN). METHODS We retrospectively analyzed 98 pregnancies in 57 women previously diagnosed with SLE who gave birth at our hospital. RESULTS There were 44 pregnancies in women with a history of LN and 54 pregnancies in those without. Fetal loss was observed in 16.1% of SLE pregnancies when excluding induced abortion, and preeclampsia and SLE flare were observed in 12.2 and 6.1% of SLE pregnancies, respectively. No significant differences were evident between women with or without LN in rate of fetal loss, preeclampsia or SLE flare. Women with a history of LN exhibited a significantly shorter duration of gestation (37.0 weeks vs. 38.4 weeks, P = 0.006) and lower birth weight (2484 g vs. 2746 g, P = 0.007) than those without LN. Multivariate analysis revealed glucocorticoid dose but not history of LN, as an independent risk factor for preterm delivery and low birth weight. CONCLUSION This study was unable to conclude that a history of LN predicted pregnancy outcomes among SLE women. Instead, a higher dose of glucocorticoid at conception was unexpectedly associated with preterm delivery and low birth weight. Further studies are awaited to verify the relationship.
Collapse
|
11
|
Bansal S, Okoye O, Rajora N. Pregnancy and lupus nephritis in developing countries: A systematic review. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:10-20. [PMID: 32129193 DOI: 10.4103/1319-2442.279928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and lupus nephritis (LN) have a significant impact on the course of pregnancy, as well as on maternal and fetal outcomes. LN in pregnancy can increase the maternal risks of SLE flare, acute kidney injury, preeclampsia, and even death. It also affects fetal outcomes by the increased risk of intrauterine growth retardation, premature delivery, and fetal loss. Successful pregnancy outcomes have been well documented in the developed world, but less is known about patients in developing nations. We searched PubMed and Google scholar for all articles published from 1999 to 2016 in developing countries. Twelve of 13 studies were included excluding only one. All studies were independently reviewed. Most of the studies reported a significant association between high flare rates of LN and higher rates of disease flare. Higher rates of active disease at conception were associated with lower live birth rates. Similarly, high flare rates of LN were associated with higher rates of fetal loss. With regard to geographic trends, Indian studies reported lower overall live birth rates and higher rates of active disease at conception. Interestingly, lower rates of preeclampsia were also noted in Indian studies. Higher rates of flare were observed in other Asian studies, but not the Indian studies. Although LN and active SLE at conception are associated with poor fetal outcomes, better outcomes are possible with proper management, even in low-resource settings. More research is necessary to fully understand the relationships between active disease at conception or LN and flare rates, live birth rates, and fetal loss rates in developing countries.
Collapse
Affiliation(s)
- Sukriti Bansal
- Michael E. DeBakey Department of Surgery, Baylor College of Surgery, Houston; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ogochukwu Okoye
- Department of Internal Medicine, Faculty of Heath Sciences, Delta State University, Abraka, Nigeria
| | - Nilum Rajora
- Nephrology Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
12
|
Yap DYH, Thong KM, Yung S, Tang C, Ma BMY, Chan TM. Antiphospholipid antibodies in patients with lupus nephritis: clinical correlations and associations with long-term outcomes. Lupus 2019; 28:1460-1467. [PMID: 31594451 DOI: 10.1177/0961203319879990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Whether the presence or absence of antiphospholipid antibodies (aPL) in patients with lupus nephritis (LN) is associated with differences in clinical outcomes remains unclear. We reviewed LN patients at a single centre during 2000-2017, and compared the clinical features and long-term outcomes between patients who were seropositive or seronegative for aPL. aPL was detected in 53/149 (35.6%) patients with biopsy-proven LN, and anticardiolipin IgM, anticardiolipin IgG, anti-β2 glycoprotein I and lupus anticoagulant was detected in 18.8%, 18.1%, 10.7% and 8.1%, respectively. Follow-up was 155.8 ± 61.0 months, and was similar between aPL-seropositive and -seronegative patients. aPL seropositivity persisted in 94.3% of patients during remission. aPL-seropositive patients showed inferior patient survival (91% and 85% at 10 and 15 years, respectively, compared to 99% and 95% in aPL-seronegative patients; p = 0.043). Nine (6.0%) patients died during follow-up, including six aPL-seropositive (four thrombotic events and two bleeding complications related to anticoagulation) and three aPL-seronegative patients. aPL seropositivity was associated with more rapid decline in estimated glomerular filtration rate (-1.44 mL/min/year compared to -0.38 mL/min/year in aPL-seronegative patients; p = 0.027) and inferior long-term renal survival (82% and 74% at 10 and 15 years, respectively, compared to 91% and 87% in aPL-seronegative patients; p = 0.034). aPL-seropositive patients also had a higher incidence of thrombotic events and miscarriage (32.1% and 13.2%, respectively, compared to 16.7% and 2.1% in the aPL-seronegative group; p = 0.030 and 0.006). We concluded that aPL seropositivity was associated with inferior long-term patient and renal survival and more frequent thrombotic events and miscarriage in LN patients.
Collapse
Affiliation(s)
- D Y H Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - K M Thong
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - S Yung
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - C Tang
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - B M Y Ma
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - T M Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| |
Collapse
|
13
|
Chen D, Yuan S, Lao M, Zhan Y, Xu H, Liang L, Cai X, Wang X, Zhan Z. Umbilical arterial Doppler ultrasonography predicts late pregnancy outcomes in patients with lupus nephritis: a multicenter study from southern China. Lupus 2019; 28:1312-1319. [PMID: 31495267 DOI: 10.1177/0961203319873702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To investigate the fetal adverse pregnancy outcomes (APOs) and the predictive value of umbilical arterial Doppler ultrasonography in the third trimester in pregnant women with lupus nephritis (LN). METHODS A retrospective cohort study enrolling 203 LN patients from 2007 to 2017 was performed. Ultrasonic parameters were recorded. RESULTS Fetal APOs occurred in 103 patients (103/203, 50.7%). Sixty-six pregnancies (66/203, 32.5%) ended with preterm births. The incidence rate of intrauterine growth restriction (IUGR) was 18.2% (37/203). Fetal distress was noted in 23 pregnancies (23/203, 11.3%). All the Doppler parameters elevated in patients with IUGR, fetal distress, and composite conditions. Resistance index (RI) indicated the highest risk of IUGR and composite APOs. The cutoff values were 0.66 and 0.67, respectively. Sensitivities were 51.4% and 33.7%, and specificities were 87.4% and 92.1%. Peak velocity of the umbilical arteries at end-systole (Vmax, abbreviated as S) to that at end-diastole (Vmin, abbreviated as D) (S/D) ratio was also a best predictor for IUGR, with the optimal cutoff value of 2.88. Sensitivity and specificity were comparable with RI. Pulsatility index (PI) over 0.84 was an ideal indicator for fetal distress with an optimal combination of sensitivity (89.5%) and specificity (51.6%). CONCLUSIONS Fetal complications were frequent in patients with LN. Umbilical arterial Doppler ultrasonography was a useful measure to predict late IUGR, fetal distress, and the composite APOs.
Collapse
Affiliation(s)
- D Chen
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - S Yuan
- Department of Rheumatology, South China University of Technology, Guangzhou, China
| | - M Lao
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Y Zhan
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - H Xu
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - L Liang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - X Cai
- Department of Rheumatology, South China University of Technology, Guangzhou, China
| | - X Wang
- Department of Ultrasound, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Z Zhan
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
14
|
Maynard S, Guerrier G, Duffy M. Pregnancy in Women With Systemic Lupus and Lupus Nephritis. Adv Chronic Kidney Dis 2019; 26:330-337. [PMID: 31733717 DOI: 10.1053/j.ackd.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/12/2019] [Accepted: 08/19/2019] [Indexed: 11/11/2022]
Abstract
Pregnancy is an altered immunologic state in which hormonal changes impact the immune system to enable maternal tolerance of the fetus. These hormonal and immunologic changes may affect disease activity in systemic lupus erythematosus. Conversely, lupus nephritis and its complications may adversely impact pregnancy. Systemic lupus erythematosus increases the risk of pre-eclampsia and its complications, including preterm birth and intrauterine growth restriction. Comorbidities such as impaired kidney function and hypertension confer additional risk and complexity. Medications used to treat lupus nephritis may impact the fetus, so therapy needs to be tailored to balance maternal benefit and fetal risk. The diagnosis of lupus nephritis during pregnancy can be difficult, as it shares overlapping features with pre-eclampsia. Kidney biopsy is generally safe in pregnancy, and should be considered if the result will affect management. Here we review the clinical aspects of counseling, diagnosis, and management of lupus nephritis in pregnancy.
Collapse
|
15
|
Williams A, Grantz K, Seeni I, Robledo C, Li S, Ouidir M, Nobles C, Mendola P. Obstetric and neonatal complications among women with autoimmune disease. J Autoimmun 2019; 103:102287. [PMID: 31147159 PMCID: PMC6708459 DOI: 10.1016/j.jaut.2019.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/14/2019] [Accepted: 05/18/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The impact of autoimmune diseases on pregnancy remains understudied on a population level. Examination of obstetric and neonatal outcomes among women with autoimmune disease and their infants can provide important insights for clinical management. METHODS Autoimmune diseases and outcomes were identified using medical records. Cesarean delivery, preterm birth, preeclampsia, small for gestational age (SGA), neonatal intensive care (NICU) admission, neonatal respiratory distress syndrome (RDS), and perinatal mortality risk was assessed. Poisson regression with robust standard errors estimated relative risks (RR) and 95% confidence intervals (95% CI) with adjustment for maternal characteristics and other chronic conditions. RESULTS Women with T1DM were at increased risk for nearly all outcomes including RDS (RR: 3.62; 95% CI: 2.84, 4.62), perinatal mortality (RR: 2.35; 95% CI: 1.12, 4.91), cesarean delivery (RR: 2.16; 95% CI: 2.02, 2.32) and preterm birth (RR: 3.52; 95% CI: 3.17, 3.91). Women with SLE also had higher risk for preterm delivery (RR: 2.90; 95% CI: 2.42, 3.48) and RDS (RR:2.99; 95% CI: 1.99, 4.51) as did women with Crohn's (cesarean delivery RR:1.31, 95% CI: 1.08, 1.60; preterm delivery RR: 1.84, 95% CI: 1.37, 2.49. RA increased risk for SGA (RR:1.66; 95% CI: 1.08, 2.55). CONCLUSION(S) Despite the heterogeneity in autoimmune diseases, we observed elevated preterm birth risk for most women with autoimmune disease. SLE and T1DM appeared to confer increased risk for a wide range of adverse outcomes.
Collapse
Affiliation(s)
- Andrew Williams
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Katherine Grantz
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Indulaxmi Seeni
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Candace Robledo
- Department of Population Health and Biostatistics, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX, USA
| | - Shanshan Li
- Slone Epidemiology Center, Boston University School of Medicine, Boston, MA, USA
| | - Marion Ouidir
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Carrie Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Pauline Mendola
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| |
Collapse
|
16
|
Udupa V, Keepanasseril A, Vijayan N, Basu D, Negi VS. Early Onset Pre-Eclampsia with Nephrotic Range Proteinuria as the Initial Manifestation of Lupus Nephritis: Report of three cases. Sultan Qaboos Univ Med J 2019; 19:e73-e76. [PMID: 31198600 PMCID: PMC6544068 DOI: 10.18295/squmj.2019.19.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/03/2019] [Accepted: 01/31/2019] [Indexed: 11/16/2022] Open
Abstract
Early onset pre-eclampsia (pre-eclampsia at less than 34 gestational weeks) is a severe form of preeclampsia; in addition, some women may also develop nephrotic range proteinuria. De novo diagnosis of lupus nephritis (LN) in pregnancy is challenging as it may present with features similar to commonly occurring preeclampsia. We report three cases of early onset pre-eclampsia with nephrotic range proteinuria and subsequent diagnosis of LN at the Women and Children hospital attached to Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, between 2014 and 2017. These cases highlights the need for further evaluation of the association between nephrotic-range proteinuria and early onset pre-eclampsia. The index of suspicion for underlying LN of these type of cases should be high. Earlier detection of LN will prompt better management that can avert or delay short- and long-term morbidity.
Collapse
Affiliation(s)
- Vinita Udupa
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Neeraja Vijayan
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Debadatta Basu
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| |
Collapse
|
17
|
Rodrigues BC, Lacerda MI, Ramires de Jesús GR, Cunha Dos Santos F, Ramires de Jesús N, Levy RA, Klumb EM. The impact of different classes of lupus nephritis on maternal and fetal outcomes: a cohort study of 147 pregnancies. Lupus 2019; 28:492-500. [PMID: 30776967 DOI: 10.1177/0961203319829825] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the impact of different classes of lupus nephritis as risk variables for maternal and fetal adverse outcomes in a cohort of pregnant lupus patients. METHODS This is a cohort study with retrospective and prospective data collection, conducted at the University Hospital of State University of Rio de Janeiro, Brazil, from 2011 to 2016. A total of 147 pregnancies of 137 systemic lupus erythematosus patients of whom 66 had lupus nephritis were included. Demographic and clinical features, as well as maternal and fetal outcomes were observed for each nephritis histological class among systemic lupus erythematosus patients and compared with those without nephritis. Categorical variables were expressed as absolute and relative frequencies and numerical variables as means and standard deviation. The chi-square test with Fisher's correction and Student's t-test were used for statistical analysis. A pvalue < 0.05 was considered statistically significant. RESULTS Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV, n = 54) presented more frequent disease flares ( p = 0.02), continuous active disease during pregnancy and puerperium ( p = 0.006), hospitalization due to systemic lupus erythematosus ( p < 0.001), hospitalization not directly associated to systemic lupus erythematosus ( p = 0.04), higher frequency of cesarean delivery ( p = 0.03) and preeclampsia ( p = 0.01) than patients without nephritis. Permanent damage measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was more frequent in classes III/IV than among the other patients. The frequency of adverse fetal outcomes such as prematurity and admission to neonatal intensive care unit were not different among systemic lupus erythematosus patients with or without nephritis. However, perinatal deaths were more frequent in patients with all classes of nephritis ( p = 0.003). CONCLUSION Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV) have a higher frequency of adverse maternal outcomes. This is probably due to the major impact of proliferative forms of nephritis on women's global heath, which is corroborated by the higher Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index findings, although we cannot exclude the negative influence of disease activity for the maternal adverse events. The findings indicate a need for further lupus nephritis classification beyond the nonspecific term nephritis in the context of lupus pregnancy as the impact on maternal and fetal outcomes varies according to histological class.
Collapse
Affiliation(s)
- B Costa Rodrigues
- 1 Department of Obstetrics, State University of Rio de Janeiro, Brazil
| | | | | | | | | | - R A Levy
- 2 Department of Rheumatology, State University of Rio de Janeiro, Brazil
| | - E Mendes Klumb
- 2 Department of Rheumatology, State University of Rio de Janeiro, Brazil
| |
Collapse
|
18
|
Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
|
19
|
Karachalios C, Bakas P, Beta A, Deligeoroglou E. Postpartum nephrotic syndrome related to new onset of systemic lupus erythematosus: A case report. Case Rep Womens Health 2018; 20:e00083. [PMID: 30425933 PMCID: PMC6222280 DOI: 10.1016/j.crwh.2018.e00083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022] Open
Abstract
Postpartum nephrotic syndrome in a pregnant woman with rheumatoid arthritis in long-standing remission is rare. Systemic lupus erythematosus can remain undiagnosed, especially in the absence of clinical manifestations. We present the case of a 34-year-old woman (gravida 2, para 1) who underwent a lower-segment cesarean section at 34 weeks and 6 days of gestation because she had developed preeclampsia and nephrotic syndrome. The concomitant presence of significant hypoproteinemia, hypoalbuminemia, uremia, elevated creatinine serum levels, hyperuricemia and hypertriglyceridemia is indicative of impaired renal function and nephrotic syndrome. This woman was diagnosed with systemic lupus erythematosus nephritis. It is imperative for clinicians to investigate the exact pathophysiological causes of nephrotic syndrome with onset in the puerperium and implement the appropriate therapeutic regimens. New onset of systemic lupus erythematosus rarely leads to postpartum nephrotic syndrome in women with rheumatoid arthritis. Lupus flares can also occur in the puerperium and often involve renal function.
Collapse
Affiliation(s)
- Charalampos Karachalios
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Panagiotis Bakas
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Anastasia Beta
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Efthimios Deligeoroglou
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| |
Collapse
|
20
|
Wu J, Ma J, Zhang WH, Di W. Management and outcomes of pregnancy with or without lupus nephritis: a systematic review and meta-analysis. Ther Clin Risk Manag 2018; 14:885-901. [PMID: 29785115 PMCID: PMC5955382 DOI: 10.2147/tcrm.s160760] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Although it is well established that systemic lupus erythematosus (SLE) negatively affects pregnancy outcomes, there is insufficient evidence on the effect of lupus nephritis (LN) on antenatal management and pregnancy outcomes. We performed a systematic review and meta-analysis to determine the association of LN with management and pregnancy outcomes in SLE patients. Methods Embase, Medline, Cochrane, and ClinicalTrials.gov were carefully searched for relevant English and Chinese language studies. A total of 2,987 articles were reviewed. Data were extracted that compared management and pregnancy outcomes in SLE pregnant women with LN vs without LN. Risk of bias was assessed by a modified version of the Newcastle-Ottawa Scale and the STROBE checklist. Combined odds ratios (OR) and 95% confidence intervals (CI) were obtained and sensitivity analysis was performed using RevMan 5.3 software. Results Sixteen studies, including 1,760 pregnant patients with SLE, were included. Gestational hypertension (OR=5.65, 95% CI=2.94–10.84), preeclampsia (OR=2.84, 95% CI=1.87–4.30), SLE flare (OR=2.66, 95% CI=1.51–4.70), renal flare (OR=15.18, 95% CI=5.89–39.14), proteinuria (OR=8.86, 95% CI=4.75–16.52), and hypocomplementemia (OR=2.86, 95% CI=1.68–4.87) were significantly affected in pregnant women with LN. Anti-Sjögren’s syndrome-related antigen A/Ro autoantibodies were negatively associated with pregnant women with LN (OR=0.57, 95% CI=0.33–0.98). Pregnant women with LN presented a significant decrease in live births (OR=0.62, 95% CI=0.49–0.80) and a significant increase in preterm births (OR=1.92, 95% CI=1.49–2.49) and fetal growth restriction (OR=1.43, 95% CI=1.08–1.91). Regarding antenatal management, steroids (OR=2.48, 95% CI=1.59–3.87) and immunosuppressant treatment (OR=6.77, 95% CI=3.30–13.89) were more frequently used in women with LN. Conclusion This review identified a significant association between the aforementioned outcomes and SLE pregnant patients with LN. In patients with SLE, LN increased the risks for adverse pregnancy outcomes and the use of medication. Therefore, special treatment and close monitoring should be allocated to pregnant women with LN.
Collapse
Affiliation(s)
- Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Jinghang Ma
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Wei-Hong Zhang
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| |
Collapse
|
21
|
|
22
|
Maternal and Perinatal Outcome in Women with Systemic Lupus Erythematosus: A Retrospective Bicenter Cohort Study. J Immunol Res 2017; 2017:8245879. [PMID: 29094052 PMCID: PMC5637847 DOI: 10.1155/2017/8245879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined. Methods Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed. Results Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7. Conclusion In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.
Collapse
|
23
|
Abstract
With the increasing prevalence of chronic kidney disease (CKD) worldwide, the number of pregnant women with various degrees of renal dysfunction is expected to increase. There is a bidirectional relation between CKD and pregnancy in which renal dysfunction negatively affects pregnancy outcomes, and the pregnancy can have a deleterious impact on various aspects of kidney disease. It has been shown that even mild renal dysfunction can increase considerably the risk of adverse maternal and fetal outcomes. Moreover, data suggest that a history of recovery from acute kidney injury is associated with adverse pregnancy outcomes. In addition to kidney dysfunction, maternal hypertension and proteinuria predispose women to negative outcomes and are important factors to consider in preconception counseling and the process of risk stratification. In this review, we provide an overview of the physiologic renal changes during pregnancy as well as available data regarding CKD and pregnancy outcomes. We also highlight the important management strategies in women with certain selected renal conditions that are seen commonly during the childbearing years. We call for future research on underexplored areas such as the concept of renal functional reserve to develop a potential clinical tool for prognostication and risk stratification of women at higher risk for complications during pregnancy.
Collapse
Affiliation(s)
- Abhilash Koratala
- From the Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville
| | - Deepti Bhattacharya
- From the Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville
| | - Amir Kazory
- From the Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville
| |
Collapse
|
24
|
Buyon JP, Kim MY, Guerra MM, Lu S, Reeves E, Petri M, Laskin CA, Lockshin MD, Sammaritano LR, Branch DW, Porter TF, Sawitzke A, Merrill JT, Stephenson MD, Cohn E, Salmon JE. Kidney Outcomes and Risk Factors for Nephritis (Flare/ De Novo) in a Multiethnic Cohort of Pregnant Patients with Lupus. Clin J Am Soc Nephrol 2017; 12:940-946. [PMID: 28400421 PMCID: PMC5460714 DOI: 10.2215/cjn.11431116] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/16/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney disease is a critical concern in counseling patients with lupus considering pregnancy. This study sought to assess the risk of renal flares during pregnancy in women with previous lupus nephritis in partial or complete remission, particularly in those with antidouble-stranded DNA antibodies and low complement levels, and the risk of new-onset nephritis in patients with stable/mildly active SLE. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We assessed active nephritis (renal flares and de novo kidney disease) and associated predictors during pregnancy in patients with lupus with urine protein ≤1000 mg and serum creatinine <1.2 mg/dl at baseline; 373 patients (52% ethnic/racial minorities) enrolled between 2003 and 2012 were prospectively followed in the Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Syndrome and Systemic Lupus Erythematosus Study. Active nephritis was defined by proteinuria increase of >500 mg and/or red blood cell casts. RESULTS Of 118 patients with previous kidney disease, 13 renal flares (11%) occurred (seven of 89 in complete remission and six of 29 in partial remission) compared with four with de novo kidney involvement (2%) in 255 patients without past kidney disease (P<0.001). Active nephritis was not associated with ethnicity, race, age, creatinine, BP, or antihypertensive and other medications. In multivariable logistic regression analyses, patients with past kidney disease in complete or partial remission more often experienced active nephritis (adjusted odds ratio, 6.88; 95% confidence interval, 1.84 to 25.71; P=0.004 and adjusted odds ratio, 20.98; 95% confidence interval, 4.69 to 93.98; P<0.001, respectively) than those without past kidney disease. Low C4 was associated with renal flares/de novo disease (adjusted odds ratio, 5.59; 95% confidence interval, 1.64 to 19.13; P<0.01) but not low C3 or positive anti-dsDNA alone. CONCLUSIONS De novo kidney involvement in SLE, even in ethnic/racial minorities, is uncommon during pregnancy. Past kidney disease and low C4 at baseline independently associate with higher risk of developing active nephritis. Antibodies to dsDNA alone should not raise concern, even in patients with past kidney disease, if in remission.
Collapse
Affiliation(s)
- Jill P Buyon
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Danlos FX, Cohen Aubart F, Vauthier-Brouzes D, Rouvier P, Nizard J, Cluzel P, Mathian A, Le Thi-Huong Boutin D, Bonotte B, Dommergues M, Amoura Z. Successful outcome of proliferative lupus nephritis during pregnancy: Toward a modern paradigm of lupus pregnancy? Eur J Obstet Gynecol Reprod Biol 2017; 214:201-203. [PMID: 28549729 DOI: 10.1016/j.ejogrb.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/29/2017] [Accepted: 05/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- François-Xavier Danlos
- Service de Médecine Interne 2, Institut e3m, French Reference Center for Rare Autoimmune and Systemic Diseases, Lupus and Antiphospholipid Antibodies Syndrome, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris 75013, France
| | - Fleur Cohen Aubart
- Service de Médecine Interne 2, Institut e3m, French Reference Center for Rare Autoimmune and Systemic Diseases, Lupus and Antiphospholipid Antibodies Syndrome, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris 75013, France; Paris VI University (UPMC), Sorbonnes Universités, Paris, France.
| | - Danièle Vauthier-Brouzes
- Department of Gynecology & Obstetrics, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Philippe Rouvier
- Departement of Anatomo-Pathology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Jacky Nizard
- Paris VI University (UPMC), Sorbonnes Universités, Paris, France; Department of Gynecology & Obstetrics, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Philippe Cluzel
- Cardiovascular and Interventional Radiology Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Institut e3m, French Reference Center for Rare Autoimmune and Systemic Diseases, Lupus and Antiphospholipid Antibodies Syndrome, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris 75013, France; Paris VI University (UPMC), Sorbonnes Universités, Paris, France
| | - Du Le Thi-Huong Boutin
- Service de Médecine Interne 2, Institut e3m, French Reference Center for Rare Autoimmune and Systemic Diseases, Lupus and Antiphospholipid Antibodies Syndrome, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris 75013, France; Paris VI University (UPMC), Sorbonnes Universités, Paris, France
| | - Bernard Bonotte
- Department of Internal Medicine and Clinical Immunology, CHU de Dijon - Complexe du Bocage, 14 r Paul Gaffarel, Dijon, France
| | - Marc Dommergues
- Department of Gynecology & Obstetrics, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Institut e3m, French Reference Center for Rare Autoimmune and Systemic Diseases, Lupus and Antiphospholipid Antibodies Syndrome, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris 75013, France; Paris VI University (UPMC), Sorbonnes Universités, Paris, France
| |
Collapse
|
26
|
Maternal-foetal outcomes in pregnant women with glomerulonephritides. Are all glomerulonephritides alike in pregnancy? J Autoimmun 2017; 79:91-98. [DOI: 10.1016/j.jaut.2017.01.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 11/23/2022]
|
27
|
Webster P, Lightstone L, McKay DB, Josephson MA. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int 2017; 91:1047-1056. [PMID: 28209334 DOI: 10.1016/j.kint.2016.10.045] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.
Collapse
Affiliation(s)
- Philip Webster
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Dianne B McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, California, USA
| | | |
Collapse
|
28
|
Chiu TF, Chuang YW, Lin CL, Yu TM, Chung MC, Li CY, Chung CJ, Ho WC. Long-Term Outcomes of Systemic Lupus Erythematous Patients after Pregnancy: A Nationwide Population-Based Cohort Study. PLoS One 2016; 11:e0167946. [PMID: 27992461 PMCID: PMC5167320 DOI: 10.1371/journal.pone.0167946] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/24/2016] [Indexed: 12/12/2022] Open
Abstract
Background Data on long-term maternal outcomes in patients with systemic lupus erythematosus (SLE) are lacking. The study aimed to explore the relationships among SLE, pregnancy, outcomes of end-stage renal disease (ESRD), and overall mortality. Methods We established a retrospective cohort study consisting of four cohorts: pregnant (case cohort) and nonpregnant SLE patients, as well as pregnant and nonpregnant non-SLE patients. One case cohort and three comparison cohorts were matched by age at first pregnancy and index date of pregnancy by using the Taiwan National Health Insurance Research Dataset. All study subjects were selected based on the index date to the occurrence of ESRD or overall death. Cox proportional hazard regression models and Kaplan–Meier curves were used in the analysis. Results SLE pregnant patients exhibited significantly increased risk of ESRD after adjusting for other important confounders, including immunosuppressant and parity (HR = 3.19, 95% CI: 1.35–7.52 for pregnant non-SLE; and HR = 2.77, 95% CI: 1.24–6.15 for nonpregnant non-SLE patients). No significant differences in ESRD incidence were observed in pregnant and nonpregnant SLE patients. Pregnant SLE patients exhibited better clinical condition at the baseline and a significantly lower risk of overall mortality than nonpregnant SLE patients. Conclusions Our data support current recommendations for SLE patients to avoid pregnancy until disease activity is quiescent. Multicenter recruitment and clinical information can be used to further examine the association of SLE and ESRD (or mortality) after pregnancy.
Collapse
Affiliation(s)
- Ting-Fang Chiu
- Department of Pediatrics, Taipei City Hospital, Zhongxiao Branch, Taipei, Taiwan
| | - Ya-Wen Chuang
- Division of Nephrology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University and Hospital, Taichung, Taiwan
| | - Tung-Min Yu
- Division of Nephrology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mu-Chi Chung
- Division of Nephrology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Yuan Li
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - Chi-Jung Chung
- Department of Health Risk Management, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Chao Ho
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- * E-mail:
| |
Collapse
|
29
|
Lazzaroni MG, Dall’Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 2016; 74:106-117. [DOI: 10.1016/j.jaut.2016.06.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/23/2023]
|
30
|
Kunjal R, Adam-Eldien R, Makary R, Jo-Hoy F, Heilig CW. A Unique Cause of Proteinuria in Pregnancy: Class II Lupus Nephritis with Concomitant Minimal Change Disease. Case Rep Nephrol Dial 2016; 6:101-105. [PMID: 27781205 PMCID: PMC5073675 DOI: 10.1159/000448731] [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: 05/26/2016] [Accepted: 07/26/2016] [Indexed: 11/29/2022] Open
Abstract
We report the case of a 22-year-old African American female who presented to another facility for routine follow-up in the 34th week of pregnancy with lower extremity swelling and nephrotic-range proteinuria. Although she was normotensive, it was initially thought that she had preeclampsia. She was monitored carefully and delivery was induced at 37 weeks of gestation. She was transferred to our hospital, where she was diagnosed with systemic lupus erythematosus (SLE) based on clinical and laboratory criteria. Renal biopsy revealed a surprising finding of minimal change disease (MCD) concomitant with class II lupus nephritis (LN). She was managed with pulses and then tapering doses of steroid therapy with dramatic resolution of the nephrotic syndrome. This case demonstrates not only the rare de novo occurrence of SLE in pregnancy, but the unique finding of MCD coexisting with class II LN. We propose that altered T cell activity may be the link between these seemingly distinct entities.
Collapse
Affiliation(s)
- Ryan Kunjal
- Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, Fla., USA
| | - Rabie Adam-Eldien
- Department of Nephrology, University of Florida College of Medicine, Jacksonville, Fla., USA
| | - Raafat Makary
- Department of Pathology, University of Florida College of Medicine, Jacksonville, Fla., USA
| | - Francois Jo-Hoy
- Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, Fla., USA
| | - Charles W Heilig
- Department of Nephrology, University of Florida College of Medicine, Jacksonville, Fla., USA
| |
Collapse
|
31
|
Fredi M, Gregorini G, Zatti S, Lojacono A, Tincani A. Identifying and managing lupus nephritis during pregnancy. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1228452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
32
|
Abstract
The management of lupus nephritis in pregnancy presents a diagnostic and therapeutic challenge for providers. Pregnancy creates a series of physiologic changes in the immune system and kidney that may result in an increased risk of disease flare and adverse maternal and fetal outcomes, such as preeclampsia, fetal loss, and preterm delivery. Conception should be delayed until disease is in remission to ensure the best pregnancy outcomes. Maternal disease activity and fetal well-being should be monitored closely by an interdisciplinary team, including obstetricians, rheumatologists, and nephrologists throughout pregnancy. Careful attention must be paid to the dosing and potential teratogenicity of medications.
Collapse
Affiliation(s)
- Andrea G Kattah
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
33
|
Rao D, Chaudhari NK, Moore RM, Jim B. HELLP syndrome: a diagnostic conundrum with severe complications. BMJ Case Rep 2016; 2016:bcr-2016-216802. [PMID: 27535735 DOI: 10.1136/bcr-2016-216802] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome is believed to be part of the spectrum of pre-eclampsia, which falls within the category of hypertensive disorders of pregnancy. Maternal and fetal complications are more severe in HELLP as opposed to pre-eclampsia alone. We describe a 26-year-old primigravida woman with no medical history who presents with signs of HELLP with marked transaminitis and mild disseminated intravascular coagulation at 35 weeks of gestation who required emergent delivery of the fetus; the patient also sustained acute kidney injury requiring continuous veno-venous hemodiafiltration and a prolonged intensive care unit admission. Remarkably, with supportive care, all laboratory derangements, including renal function, normalised after 4 weeks. We discuss the diagnostic conundrum when faced with the possible diagnosis of HELLP in discriminating from its many imitators in order to assume proper treatment.
Collapse
Affiliation(s)
- Devika Rao
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| | | | | | - Belinda Jim
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| |
Collapse
|
34
|
Fitzpatrick A, Mohammadi F, Jesudason S. Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby. Int J Womens Health 2016; 8:273-85. [PMID: 27471410 PMCID: PMC4948734 DOI: 10.2147/ijwh.s76819] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.
Collapse
Affiliation(s)
| | - Fadak Mohammadi
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital
| | - Shilpanjali Jesudason
- Women's and Babies Division, Women's and Children's Hospital; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital; Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
35
|
Shakya S, Yang Z. New-onset systemic lupus erythematosus during pregnancy: A challenge in diagnosis. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jrhm.2016.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
36
|
Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
Collapse
Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
| |
Collapse
|
37
|
Hannah J, Casian A, D'Cruz D. Tacrolimus use in lupus nephritis: A systematic review and meta-analysis. Autoimmun Rev 2015; 15:93-101. [PMID: 26427983 DOI: 10.1016/j.autrev.2015.09.006] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022]
Abstract
There is growing interest in the role of tacrolimus as a potential therapeutic agent in SLE. This systematic review and meta-analysis evaluates the evidence for tacrolimus use in the management of lupus nephritis. Thirteen controlled studies were identified (9 suitable for inclusion), using Cochrane database, SCOPUS, Web of Science and OVID (MEDLINE and EMBASE). Data on complete and partial remission rates, proteinuria reduction and adverse events was extracted and analysed using RevMan software. The meta-analysis showed that overall tacrolimus is more effective at inducing complete renal remission than IVCYC (p=0.004), but there is no significant difference compared to MMF (p=0.87). Multi-target TAC+MMF therapy is more effective than IVCYC only when partial remission is included (p=0.0006). Frequency of key adverse effects seems comparable to other agents used in the management of lupus nephritis with fewer gastrointestinal side effects, leukopenia, menstrual disorders, infections and episodes of liver dysfunction reported, but more new onset hypertension and hyperglycaemia. Mortality was lower in the tacrolimus groups, but this was not statistically significant (p=0.15). Tacrolimus may be more effective at reducing proteinuria, but again this was not statistically significant. There are no controlled trials looking at use in pregnancy or juvenile patients, however case reports suggest potential efficacy and safety. In conclusion, in moderately severe lupus nephritis, there is some evidence supporting efficacy of tacrolimus or multi-target TAC+MMF over IVCYC, but no evidence supporting tacrolimus over MMF. Tacrolimus may be more effective at reducing proteinuria, having potential implications for long-term outcome. Key limitations of this study are the lack of long-term outcome data and the lack of high quality, large, blinded controlled trials in multi-ethnic groups.
Collapse
Affiliation(s)
- Jennifer Hannah
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL.
| | - Alina Casian
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL.
| | - David D'Cruz
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL. david.d'
| |
Collapse
|
38
|
de Macedo JF, de Macedo GC, Campos LA, Baltatu OC. Successful Pregnancy Following Assisted Reproduction in Woman With Systemic Lupus Erythematosus and Hypertension: A Case Report. Medicine (Baltimore) 2015; 94:e1531. [PMID: 26376400 PMCID: PMC4635814 DOI: 10.1097/md.0000000000001531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with systemic lupus erythematosus have a poor prognosis of pregnancy, since it is associated with significant maternal and fetal morbidity, including spontaneous miscarriage, pre-eclampsia, intrauterine growth restriction, fetal death and pre-term delivery. We report a case with successful pregnancy in a patient with systemic lupus erythematosus and hypertension. A 39-year-old nulliparous woman presented with systemic lupus erythematosus with antinuclear and antiphospholipid antibodies, hypertension and recurrent pregnancy loss presented for assisted reproduction. The patient responded well to enoxaparin and prednisone during both assisted reproduction and prenatal treatment. This case report indicates that prescription of immunosuppressant and blood thinners can be safely recommended throughout the whole prenatal period in patients with systemic lupus erythematosus. Enoxaparin and prednisone may be prescribed concurrently during pregnancy.
Collapse
Affiliation(s)
- José Fernando de Macedo
- From Reproferty Reproductive Medicine Clinic, Sao Jose dos Campos, São Paulo, Brazil (JFdM, GCdM, LAC); Center of Innovation, Technology and Education (CITE), Camilo Castelo Branco University, Sao Jose dos Campos, Sao Paulo, Brazil (JFdM, LAC, OCB); and Faculty of Medicine, Estácio de Sá University, Rio de Janeiro, Brazil (GCDM)
| | | | | | | |
Collapse
|
39
|
Understanding and Managing Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015:943490. [PMID: 26246905 PMCID: PMC4515284 DOI: 10.1155/2015/943490] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/31/2015] [Indexed: 12/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.
Collapse
|
40
|
Pregnancy in Chronic Kidney Disease: questions and answers in a changing panorama. Best Pract Res Clin Obstet Gynaecol 2015; 29:625-42. [DOI: 10.1016/j.bpobgyn.2015.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 02/18/2015] [Accepted: 02/23/2015] [Indexed: 01/10/2023]
|
41
|
Clinical outcomes and predictors of fetal and maternal consequences of pregnancy in lupus nephritis patients. Int Urol Nephrol 2015; 47:1379-85. [DOI: 10.1007/s11255-015-1032-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/07/2015] [Indexed: 01/16/2023]
|
42
|
Koh JH, Ko HS, Lee J, Jung SM, Kwok SK, Ju JH, Park SH. Pregnancy and patients with preexisting lupus nephritis: 15 years of experience at a single center in Korea. Lupus 2015; 24:764-72. [DOI: 10.1177/0961203315572715] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 01/21/2015] [Indexed: 01/06/2023]
Abstract
We investigated obstetric outcomes and comorbidities during pregnancy in females with preexisting lupus nephritis (LN) and identified predictors for renal flare. In cases of renal flare during pregnancy, we assessed the long-term post-delivery renal outcome. We performed a retrospective analysis of 183 systemic lupus erythematosus (SLE) pregnancies including blood chemistry, urinalysis, urinary protein, and disease activity recorded at prepregnancy, during pregnancy, and at one month, six months, and one year post-delivery. Pregnancies with preexisting LN had a greater frequency of adverse obstetric outcomes and maternal comorbidity. Renal flares occurred in 50.7% of pregnancies with preexisting LN, 89.2% of which were reactivations. Renal flare among pregnancies with SLE was predicted based on preexisting lupus nephritis (OR 17.73; 95% CI, 5.770–54.484), an active disease prior to pregnancy (OR 2.743; 95% CI, 1.074–7.004), and prepregnancy eGFR < 90 ml/min/1.73 m2 (OR 11.151; 95% CI, 3.292–37.768). Persistent LN one year after delivery was observed in 33.3% of pregnancies. The median follow-up time after delivery was 5.9 (3.1–9.7) years and chronic kidney disease (CKD) occurred in 21.4% of pregnancies with renal flare. In patients with renal flare, failing to achieve a ≥ 50% reduction in urine protein levels within six months, longer total duration of renal flare, and acute kidney injury at renal flare was associated with CKD development. Females with preexisting LN should achieve remission before pregnancy. When patients experience renal flares during pregnancy, it is important to reduce the proteinuria level by >50% within six months and to achieve early remission for excellent long-term renal outcomes.
Collapse
Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine
| | - H S Ko
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Lee
- Division of Rheumatology, Department of Internal Medicine
| | - S M Jung
- Division of Rheumatology, Department of Internal Medicine
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine
| |
Collapse
|
43
|
Petri M, Daly RP, Pushparajah DS. Healthcare costs of pregnancy in systemic lupus erythematosus: retrospective observational analysis from a US health claims database. J Med Econ 2015; 18:967-73. [PMID: 26121160 DOI: 10.3111/13696998.2015.1066796] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus is a complex autoimmune disease, most frequently affecting women of childbearing age. Women with lupus are at increased risk of pregnancy complications that are exacerbated by active disease. Despite this, their use of medications and hospital resources has not been extensively studied. METHODS Retrospective analyses of the Truven Health MarketScan database (2006-2012) aimed to quantify drug and resource utilization in pregnant women with lupus, as well as the incidence of pregnancy complications in these patients. Records of women aged 12-54 were reviewed and both lupus patients and pregnancies identified. Pregnant women with lupus were matched 1:5 with either pregnant women without lupus, or non-pregnant women with lupus. RESULTS Pregnancies with lupus were associated with increased complications when compared to pregnancies without lupus. During pregnancy, the use of immunosuppressants decreased in pregnant women with lupus, as did rheumatologist visits, while the number of women not treated with any immunosuppressant increased. Pregnant women with lupus showed higher overall treatment costs than controls. However, compared to non-pregnant women with lupus, medication costs actually dropped, possibly due to the withdrawal of medications from these patients or women becoming pregnant while disease activity was low. CONCLUSIONS The large database analyses reported here revealed that pregnancies in women with lupus were associated with a higher risk of complications, higher healthcare costs, and fewer prescribed medications, including immunosuppressants, than the control groups. The increased risk of complications and decreased immunosuppressant use suggest that patients require additional guidance from physicians to give them the best chance of experiencing a safe pregnancy. Indeed, despite the recognized role active lupus plays in increasing pregnancy complications, women with lupus had fewer rheumatology visits during pregnancy, although their visits to their general practitioner/primary healthcare provider increased, highlighting the need for team-based co-ordination care between OBGYN physicians and rheumatologists.
Collapse
Affiliation(s)
- M Petri
- a a Division of Rheumatology , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - R P Daly
- b b Lupus Foundation of America , Washington , WA , USA
| | | |
Collapse
|
44
|
Karras A. [Lupus nephritis: up-to-date]. Rev Med Interne 2014; 36:98-106. [PMID: 25443980 DOI: 10.1016/j.revmed.2014.09.006] [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: 05/12/2014] [Revised: 09/11/2014] [Accepted: 09/13/2014] [Indexed: 10/24/2022]
Abstract
Renal involvement is frequent during natural history of systemic lupus erythematosus (SLE) and has a major prognostic value in this systemic disease. Screening for renal symptoms, such as proteinuria, micro-haematuria or renal failure must be performed at initial diagnosis and repeated during subsequent follow-ups. Any significant abnormality of these parameters may reveal active glomerulonephritis (GN) and should lead to a renal biopsy, which will significantly impact the therapeutic choices. Proliferative GN, defined as class III or IV by the actual histo-pathological classification, is the most severe form of SLE-associated nephropathy and can lead to end-stage renal disease (ESRD) in up to 60% of cases, according to ethnicity and follow-up duration. Standard induction treatment of active proliferative GN includes corticosteroids combined with an immunosuppressive drug, which can either be cyclophosphamide or mycophenolate mofetil (MMF). Even though, recent biotherapies have not yet proved their efficacy in the field of lupus nephritis, new protocols are expected, aiming higher remission rates and avoidance of high-dose corticosteroids regimens. When remission is achieved in proliferative GN, a maintenance therapy is required to decrease the risk of relapse, using either azathioprine or MMF. Immunosuppressive drugs are responsible for an increased risk of infectious or neoplastic complications but cardiovascular disease is actually one of the main causes of mortality among lupus patients, especially for patients with SLE-related kidney disease, well before reaching ESRD.
Collapse
Affiliation(s)
- A Karras
- Service de néphrologie, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
| |
Collapse
|
45
|
Koh JH, Ko HS, Kwok SK, Ju JH, Park SH. Hydroxychloroquine and pregnancy on lupus flares in Korean patients with systemic lupus erythematosus. Lupus 2014; 24:210-7. [DOI: 10.1177/0961203314555352] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the clinical and laboratory characteristics of pregnancies with systemic lupus erythematosus (SLE) and identified lupus flare predictors during pregnancy. Additionally, we examined lupus activity and pregnancy outcomes in SLE patients who continued, discontinued or underwent no hydroxychloroquine (HCQ) treatment during pregnancy. We retrospectively analyzed 179 pregnancies in 128 SLE patients at Seoul St. Mary’s Hospital, Korea, between 1998 and 2012 and then assessed the clinical profiles and maternal and fetal outcomes. Overall, 90.5% of pregnancies resulted in a successful delivery and were divided into two groups: those who experienced lupus flares (80 pregnancies, 44.7%) and those who did not (99 pregnancies, 55.3%). Increased preeclampsia, preterm births, low birth weight, intrauterine growth restriction (IUGR), and low 1-minute Apgar scores occurred in pregnancies with lupus flares compared to pregnancies in quiescent disease. Lupus flares were predicted by HCQ discontinuation, a history of lupus nephritis, high pre-pregnancy serum uric acid and low C4 levels. Our study indicates that achieving pre-pregnancy remission and continuing HCQ treatment during pregnancy are important for preventing lupus flares.
Collapse
Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - H S Ko
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| |
Collapse
|
46
|
Chen TK, Gelber AC, Witter FR, Petri M, Fine DM. Renal biopsy in the management of lupus nephritis during pregnancy. Lupus 2014; 24:147-54. [PMID: 25249595 DOI: 10.1177/0961203314551812] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The differential diagnosis of proteinuria and hematuria in pregnancy is broad and includes active lupus nephritis. Identification of the correct diagnosis often has a profound therapeutic impact on not only the mother but also the fetus. To date, relatively few reports exist on the role of renal biopsy during pregnancy among women with systemic lupus erythematosus (SLE). We present a case series of 11 pregnant women with SLE who underwent a renal biopsy to evaluate a presumptive flare of lupus nephritis. The electronic medical record was retrospectively analyzed for pre-biopsy serum creatinine, proteinuria, hematuria, antinuclear antibodies (ANA), and antibodies to double-stranded DNA (anti-dsDNA); histologic findings on renal biopsy; and the clinical course of each mother and fetus. From 2001 to 2012, 11 pregnant women with SLE flares during pregnancy underwent a renal biopsy at an academic tertiary medical center. At the time of biopsy, median gestational age was 16 weeks (range 9 to 27), median serum creatinine was 0.6 mg/dl (interquartile range 0.5 to 0.9), six (55%) had hematuria, and all had proteinuria >500 mg/24 hours. Proliferative lupus nephritis was found in 10 (91%) of 11 biopsies (five with ISN/RPS Class III; five with ISN/RPS Class IV). All but one individual underwent a change in management guided by information gleaned from renal biopsy. No apparent biopsy-related complications occurred to mother or fetus. Three women elected to terminate their pregnancy; although many factors were involved, the findings on renal biopsy informed the decision-making process. Among the remaining cases, there were three pre-term deliveries, one fetus with complete heart block, one in utero demise, and one maternal death. Renal biopsy is helpful at informing the management of patients with lupus nephritis during pregnancy.
Collapse
Affiliation(s)
| | | | - F R Witter
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|
47
|
Webster P, Wardle A, Bramham K, Webster L, Nelson-Piercy C, Lightstone L. Tacrolimus is an effective treatment for lupus nephritis in pregnancy. Lupus 2014; 23:1192-6. [DOI: 10.1177/0961203314540353] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Lupus nephritis during pregnancy increases morbidity and mortality for mother and baby. Flares are difficult to treat as many therapeutic options are teratogenic or fetotoxic. Steroids alone may be unable to control disease activity and are associated with higher rates of preterm delivery, sepsis and gestational diabetes. Reports of using tacrolimus to treat lupus nephritis in pregnancy are limited. We describe the pregnancies of nine women in whom tacrolimus was successfully used to treat lupus nephritis flare (six patients) or maintain stable disease (three patients). Introduction or dose escalation of oral steroids was avoided in five of the patients who developed active disease and steroid dose was rapidly reduced in the sixth patient. All women with disease flare attained partial or complete remission after starting tacrolimus. None of the women on maintenance treatment developed active disease. We propose tacrolimus as an effective adjuvant or alternative therapy to steroids for treating lupus nephritis flare or maintaining stable disease during pregnancy.
Collapse
Affiliation(s)
- P Webster
- Imperial College Healthcare NHS Trust Lupus Centre, Hammersmith Hospital, London, UK
| | - A Wardle
- Imperial College Healthcare NHS Trust Lupus Centre, Hammersmith Hospital, London, UK
| | - K Bramham
- Division of Women’s Healthy, Women’s Health Academic Centre, King's College London, UK
| | - L Webster
- Division of Women’s Healthy, Women’s Health Academic Centre, King's College London, UK
| | - C Nelson-Piercy
- Division of Women’s Healthy, Women’s Health Academic Centre, King's College London, UK
| | - L Lightstone
- Imperial College Healthcare NHS Trust Lupus Centre, Hammersmith Hospital, London, UK
| |
Collapse
|
48
|
Smyth A, Radovic M, Garovic VD. Women, kidney disease, and pregnancy. Adv Chronic Kidney Dis 2013; 20:402-10. [PMID: 23978545 DOI: 10.1053/j.ackd.2013.06.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/12/2013] [Accepted: 06/17/2013] [Indexed: 12/18/2022]
Abstract
Several glomerular diseases may occur in women of childbearing age. Pregnancy in such patients should be planned when the disease has been in remission for a minimum of 6 months to minimize maternal and fetal complications. Immunosuppressive agents should be optimized before conception to include those that are safe for pregnancy. The complexity of medical management when caring for these patients calls for a multidisciplinary team approach consisting of a nephrologist, rheumatologist, obstetrician, and pharmacist. This review will address the physiological changes of pregnancy that may affect glomerular disease presentation, activity, and diagnosis; specific glomerular diseases primary and secondary to systemic diseases in the context of pregnancy; fetal and maternal complications and long-term effects; diagnosis and differential diagnosis; and treatment strategies that are considered relatively safe with respect to fetal intrauterine exposure.
Collapse
|
49
|
Craici IM, Wagner SJ, Bailey KR, Fitz-Gibbon PD, Wood-Wentz CM, Turner ST, Hayman SR, White WM, Brost BC, Rose CH, Grande JP, Garovic VD. Podocyturia predates proteinuria and clinical features of preeclampsia: longitudinal prospective study. Hypertension 2013; 61:1289-96. [PMID: 23529165 DOI: 10.1161/hypertensionaha.113.01115] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Podocyturia, the shedding of live podocytes, is present at delivery in women with preeclampsia. The aim of this study was to test whether podocyturia is present earlier in pregnancy and predicts for preeclampsia. We also aimed to compare test characteristics of podocyturia with those of angiogenic factors previously implicated in the pathogenesis of this disorder. We prospectively enrolled 315 women who provided blood and urine samples at the end of the second trimesters of their pregnancies (median, 27 gestational weeks) and within 24 hours of their deliveries (median, 39.5 gestational weeks). Blood samples were analyzed for angiogenic markers, including placental growth factor, the soluble receptor fms-like tyrosine kinase receptor-1 for vascular endothelial growth factor, and endoglin. The urine sediments were analyzed for podocytes, identified by staining for podocin after culturing the urinary sediments for 24 hours. This analysis included all women who developed preeclampsia (n=15), gestational hypertension (n=15), and a subsample of women who remained normotensive throughout pregnancy (n=44), matched for maternal age and number of previous pregnancies to those who developed preeclampsia. At the second trimester collection, all women who developed preeclampsia had podocyturia, compared with none of those who remained normotensive or were diagnosed with gestational hypertension. Podocyturia in the second trimester had a significantly greater sensitivity and specificity for the subsequent diagnosis of preeclampsia than any single angiogenic marker or a combination thereof. Screening for podocyturia at the end of the second trimester may allow for accurate identification of pregnant women at risk for preeclampsia.
Collapse
Affiliation(s)
- Iasmina M Craici
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|