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Jeyaraman D, Walters B, Bramham K, Fish R, Lambie M, Wu P. Adverse pregnancy outcomes in pregnant women with chronic kidney disease: A systematic review and meta-analysis. BJOG 2024; 131:1331-1340. [PMID: 38488268 DOI: 10.1111/1471-0528.17807] [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: 10/30/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with an increased risk of adverse pregnancy outcomes, but the risk at different stages of CKD (defined by estimated glomerular filtration rate, eGFR) compared with women without CKD has not been quantified in large cohorts. OBJECTIVES To quantify the association between CKD and adverse pregnancy outcomes according to CKD definition, CKD stage and presence or absence of diabetes. SEARCH STRATEGY A systematic search of EMBASE and MEDLINE from inception to 5 January 2023. SELECTION CRITERIA English-language randomised controlled trials as well as cohort and case-control studies investigating adverse pregnancy outcomes in pregnant women with CKD. DATA COLLECTION AND ANALYSIS Two reviewers conducted independent data extractions. A random-effects model was used to estimate risk. MAIN RESULTS We included 19 studies with 3 251 902 women. Defining CKD using eGFR or serum creatinine produced results with greater effect size but wider confidence intervals. Compared with CKD stages 1-2, women with CKD stages 3-5 have a greater risk, but also greater imprecision in the risk estimate, of the following outcomes: pre-eclampsia (OR 55.18, 95% CI 2.63-1157.68, vs OR 24.74, 95% CI 1.75-348.70), preterm birth (OR 20.24, 95% CI 2.85-143.75, vs OR 8.18, 95% CI 1.54-43.46) and neonatal intensive care unit admission (OR 19.32, 95% CI 3.07-121.68, vs OR 9.77, 95% CI 2.49-38.39). Women with diabetic kidney disease, compared with women without diabetic kidney disease, have higher risks of maternal mortality, small-for-gestational-age neonates, pre-eclampsia and gestational hypertension. CONCLUSIONS There is heterogeneity in the definition of CKD in pregnancy. Future studies should consider ways to standardise its definition and measurement in pregnancy.
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Affiliation(s)
- Deepthika Jeyaraman
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Ben Walters
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, UK
| | - Richard Fish
- Department of Nephrology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Mark Lambie
- Department of Nephrology, University Hospitals of North Midlands, Stoke-on-Trent, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Pensée Wu
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Obstetrics and Gynaecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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2
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Moroni G, Calatroni M, Donato B, Ponticelli C. Kidney Biopsy in Pregnant Women with Glomerular Diseases: Focus on Lupus Nephritis. J Clin Med 2023; 12:jcm12051834. [PMID: 36902621 PMCID: PMC10003332 DOI: 10.3390/jcm12051834] [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: 12/31/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Despite significant improvements of renal and obstetrical management, pregnancies in women with glomerular diseases and with lupus nephritis continue to be associated with increased complications both for the mother and the fetus as compared to those of pregnancies in healthy women. To reduce the risk of these complications, planning pregnancy in a phase of stable remission of the underlining disease is necessary. A kidney biopsy is an important event in any phase of pregnancy. A kidney biopsy can be of help during counselling before pregnancy in cases of incomplete remission of the renal manifestations. In these situations, histological data may differentiate active lesions that require the reinforcement of therapy from chronic irreversible lesions that may increase the risk of complications. In pregnant women, a kidney biopsy can identify new-onset systemic lupus erythematous (SLE) and necrotizing or primitive glomerular diseases and distinguish them from other, more common complications. Increasing proteinuria, hypertension, and the deterioration of kidney function during pregnancy may be either due to a reactivation of the underlying disease or to pre-eclampsia. The results of the kidney biopsy suggest the need to initiate an appropriate treatment, allowing the progression of the pregnancy and the fetal viability or the anticipation of delivery. Data from the literature suggest avoiding a kidney biopsy beyond 28 weeks of gestation to minimize the risks associated with the procedure vs. the risk of preterm delivery. In case of the persistence of renal manifestations after delivery in women with a diagnosis of pre-eclampsia, a renal kidney assessment allows the final diagnosis and guides the therapy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-345-872-1910
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Beatriz Donato
- Nephrology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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4
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Oki R, Unagami K, Kakogawa J, Beppu H, Banno T, Yagisawa T, Kanzawa T, Hirai T, Omoto K, Kitajima K, Shirakawa H, Hoshino J, Takagi T, Ishida H. Pregnancy Complications and Impact on Kidney Allograft After Kidney Transplantation in IgA Nephropathy. Transpl Int 2023; 36:11220. [PMID: 37213487 PMCID: PMC10193387 DOI: 10.3389/ti.2023.11220] [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: 01/27/2023] [Accepted: 04/21/2023] [Indexed: 05/23/2023]
Abstract
Pregnancy in kidney transplantation (KT) recipients has been challenging because of the high risk of maternal, fetal, and renal complications. Although patients with immunoglobulin A nephropathy (IgAN)-chronic kidney disease (CKD) are at a high risk for hypertension in pregnancy (HIP), the maternal risk in KT recipients with IgAN as the etiology remains unclear. We retrospectively reviewed the medical records of pregnant KT recipients who delivered at our hospital. The incidence of maternal and fetal complications and the impact on kidney allografts between the group with IgAN as the primary kidney disease and the group with other primary diseases were compared. The analysis included 73 pregnancies in 64 KT recipients. The IgAN group had a higher incidence of HIP than the non-IgAN group (69% vs. 40%, p = 0.02). IgAN as primary kidney disease and interval from transplantation to conception were associated with HIP (OR 3.33 [1.11-9.92], p = 0.03, OR 0.83 [0.72-0.96], p < 0.01, respectively). The 20-year graft survival or prevention of CKD stage 5 in group with IgAN was lower than that in the group with other primary disease (p < 0.01). KT recipients should be informed of the risk of HIP and possibility of long-term worsening of postpartum renal function.
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Affiliation(s)
- Rikako Oki
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
- *Correspondence: Kohei Unagami,
| | - Jun Kakogawa
- Department of Obstetrics and Gynecology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hiroko Beppu
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Ohkubo Hospital, Tokyo, Japan
| | - Taro Banno
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Takafumi Yagisawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kumiko Kitajima
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hiroki Shirakawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Ohkubo Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
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5
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Piccoli GB, Orozco-Guillén OA. The pathogenesis of pre-eclampsia in kidney donors. Nat Rev Nephrol 2023; 19:7-8. [PMID: 36303023 DOI: 10.1038/s41581-022-00646-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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6
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Shalaby AS, Shemies RS. Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review. J Nephrol 2022; 35:2175-2189. [PMID: 35708883 PMCID: PMC9700640 DOI: 10.1007/s40620-022-01349-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pregnancy-Related Acute kidney injury (PR-AKI) is a global health problem with substantial maternal and fetal morbidity and mortality. However, little is known about the current situation in the developing world including African countries. Africa is the poorest continent per capita, and women from Sub-Saharan Africa alone account for 66% of the estimated global maternal deaths from preventable obstetric causes. METHODS OBJECTIVE: To review the literature on the clinical profile, maternal and renal outcomes of women with PR-AKI in the African continent. SEARCH STRATEGY Medline, ISI Web of Science, Scopus, and Cochrane library were searched in February 2022, using the MeSH terms and text key words: "pregnancy", "pregnant", "acute kidney injury", "acute renal insufficiency", "acute renal injury", "acute renal failure", and "Africa". SELECTION CRITERIA AND DATA COLLECTION Studies from African countries which reported maternal and renal outcomes in women with PR-AKI during pregnancy or postpartum were included. Editorials, short communications, and case reports were excluded. The study quality was assessed using the NHLBI tool. Data extraction was done using predefined data fields. RESULTS A total of 167 studies were evaluated, of which 14 studies from seven African countries met the inclusion criteria. Preeclampsia, obstetric hemorrhage, and sepsis represented the main causes of PR-AKI. Maternal mortality ranged between 0 and 34.4%. Although the majority of women needed ICU admission and hemodialysis, renal recovery occurred in 53.1-90% of patients. Perinatal mortality has been reported to be 1.5-60.5% in the included studies. AUTHORS' CONCLUSIONS PR-AKI in Africa represents the second leading cause of AKI. Limited access to obstetric care, late referral, and late diagnosis of women with risks for PR-AKI hinder the curtailment of the problem. Provision of health care facilities with adequately trained personnel and implementation of preventive strategies will be of great value in decreasing the magnitude of the problem.
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Affiliation(s)
- Ahmed Saad Shalaby
- Mansoura-Manchester Medical Program, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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7
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Lian X, Fan L, Ning X, Wang C, Lin Y, Chen W, Chen W, Yu X. History of Adverse Pregnancy on Subsequent Maternal-Fetal Outcomes in Patients with Immunoglobulin A Nephropathy: A Retrospective Cohort Study from a Chinese Single Center. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:160-167. [PMID: 35527987 PMCID: PMC9021624 DOI: 10.1159/000520586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/16/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Gestation complications have a recurrence risk and could predispose to each other in the next pregnancy. We aimed to evaluate the relationship between a history of adverse pregnancy and maternal-fetal outcomes in subsequent pregnancy in patients with Immunoglobulin A nephropathy (IgAN). METHODS A retrospective cohort study from a Chinese single center was conducted. Pregnant women with biopsy-proven primary IgAN and aged ≥18 years were enrolled and divided into the 2 groups by a history of adverse pregnancy. The primary outcome was adverse pregnancy outcome, which included maternal-fetal outcomes. Logistical regression model was used to evaluate the association of a history of adverse pregnancy with subsequent adverse maternal and fetal outcomes. RESULTS Ninety-one women with 100 pregnancies were included, of which 54 (54%) pregnancies had a history of adverse pregnancy. IgAN patients with adverse pregnancy history had more composite maternal outcomes (70.4% vs. 45.7%, p = 0.012), while there was no difference in the composite adverse fetal outcomes between the 2 groups (55.6% vs. 45.7%). IgAN patients with a history of adverse pregnancy were associated with an increased risk of subsequent adverse maternal outcomes (adjusted odds ratio [OR], 2.64; 95% CI, 1.07-6.47). Similar results were shown in those with baseline serum albumin <3.5 g/dL, 24 h proteinuria ≥1 g/day, and a history of hypertension. There was no association between a history of adverse pregnancy and subsequent adverse fetal outcomes in IgAN patients (adjusted OR, 1.56; 95% CI, 0.63-3.87). CONCLUSION A history of adverse pregnancy was associated with an increased risk of subsequent adverse maternal outcomes, but not for adverse fetal outcomes in IgAN patients.
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Affiliation(s)
- Xingji Lian
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Li Fan
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xin Ning
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Cong Wang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Yi Lin
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Wenfang Chen
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Nephrology (Sun Yat-sen University), Guangzhou, China
- Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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8
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Tang C, Si FL, Yao YX, Lv JC, Shi SF, Chen YQ, Liu LJ, Zhang H. The efficacy and safety of hydroxychloroquine in pregnant patients with IgA nephropathy: A retrospective cohort study. Nephrology (Carlton) 2021; 27:155-161. [PMID: 34713949 DOI: 10.1111/nep.13991] [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: 08/26/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022]
Abstract
AIM Hydroxychloroquine (HCQ) is used to control proteinuria in IgA Nephropathy (IgAN) However, its efficacy and safety in pregnant IgAN patients remains unknown. This study aimed to verify the safety of HCQ in pregnant IgAN patients and compare renal function and pregnancy outcomes with those of patients not treated with HCQ. METHODS We retrospectively reviewed medical records of all pregnant IgAN patients and singleton gestations at Peking University First Hospital from 2003-2021. Patients who did and did not receive HCQ treatment during pregnancy were compared. RESULTS We found no significant pre- or post-pregnancy differences in proteinuria or renal function between the two groups. However, the HCQ (+) group had higher proteinuria at the time of kidney biopsy (2.04 [1.26, 2.56] g/d vs. 0.80 [0.44, 1.11] g/d, P < .001); the proteinuria level at HCQ therapy initiation was also higher than that at the beginning of pregnancy (1.87 [1.30, 2.59] g/d vs. 1.08 [0.75, 1.50] g/d, P = .001). Despite no difference in preterm birth, birth weight, preeclampsia or postpartum haemorrhage, the proportion of patients with a previous history of spontaneous abortion was higher in the HCQ (+) group than in the HCQ (-) group (48.0% vs. 20.6%, P = .010). The eGFR (regression coefficient, 0.981; 95%CI 0.964-0.998) was a predictive factor for obstetrical complications. CONCLUSION HCQ is safe for IgAN treatment during pregnancy with effective reduction of proteinuria. HCQ might also be helpful in patients with a history of spontaneous abortion.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Xuan Yao
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Qing Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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9
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Jan D, Michal K, Eva J, Marek M, Vladimír T, Antonín P. Chronic kidney disease and pregnancy outcomes. Sci Rep 2021; 11:21299. [PMID: 34716386 PMCID: PMC8556278 DOI: 10.1038/s41598-021-00670-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/13/2021] [Indexed: 11/09/2022] Open
Abstract
Pregnancy complicated by CKD is currently not fully understood topic. Outcome of pregnancy in patients with CKD is related to impaired glomerular filtration rate and the degree of proteinuria. In our study we evaluated the association of serum creatinine level and proteinuria with both maternal and fetal outcomes in the cohort of 84 pregnant patients with CKD. In CKD group we confirmed negative correlation of highest serum creatinine level in pregnancy to fetal weight (p value < 0.001) and gestation period (p value < 0.001). Likewise, negative correlation of preconception serum creatinine to fetal weight (p value < 0.001) and gestation period (p value 0.002). Negative correlation of proteinuria to gestation period (p value < 0.001) and fetal weight (p value < 0.001) was also demonstrated. CKD is serious risk factor for pregnancy outcome. Proteinuria and serum creatinine level should be examined before pregnancy and regularly monitored during pregnancy. Higher serum creatinine levels and higher proteinuria predispose to shorter gestation period and lower birth weight of the neonate.
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Affiliation(s)
- Dvořák Jan
- Department of Obstetrics and Gynaecology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Apolinářská 18, 128 08, Prague 2, Czech Republic
| | - Koucký Michal
- Department of Obstetrics and Gynaecology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Apolinářská 18, 128 08, Prague 2, Czech Republic
| | - Jančová Eva
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, U Nemocnice 499/2, 128 08, Prague 2, Czech Republic.
| | - Mysliveček Marek
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, U Nemocnice 499/2, 128 08, Prague 2, Czech Republic
| | - Tesař Vladimír
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, U Nemocnice 499/2, 128 08, Prague 2, Czech Republic
| | - Pařízek Antonín
- Department of Obstetrics and Gynaecology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Apolinářská 18, 128 08, Prague 2, Czech Republic
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10
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Cabiddu G, Mannucci C, Fois A, Maxia S, Chatrenet A, Osadolor S, Kimani E, Torreggiani M, Attini R, Masturzo B, Cheve MT, Piccoli GB. Preeclampsia is a valuable opportunity to diagnose chronic kidney disease: a multicentre study. Nephrol Dial Transplant 2021; 37:1488-1498. [PMID: 34338783 PMCID: PMC9317168 DOI: 10.1093/ndt/gfab225] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background Pre-eclampsia (PE) and chronic kidney disease (CKD) are known to be associated. Our objective was to assess the prevalence of CKD in a large multicentre cohort of women without acknowledged CKD who experienced a PE episode. Methods The setting for the study was France (Le Mans, Central France) and Italy (Cagliari, Sardinia). The study participants were patients who experienced PE in 2018–19, identified from the obstetric charts. Patients with known–acknowledged CKD were excluded. Only singletons were considered. Persistent (micro)albuminuria was defined as present and confirmed at least 3 months after delivery. CKD was defined according to the Kidney Disease Outcomes Quality Initiative guidelines; urinary alterations or low eGFR confirmed at a distance of at least 3 months, or morphologic changes. Patients were divided into four groups: evidence of CKD; no evidence of CKD; unclear diagnosis-ongoing work-up; or persistent microalbuminuria. The outcome ‘diagnosis of CKD’ was analysed by simple and multiple logistic regressions. Temporal series (week of delivery) were analysed with Kaplan–Meier curves and Cox analysis. Results Two hundred and eighty-two PE pregnancies were analysed (Le Mans: 162; Cagliari: 120). The incidence of CKD diagnosis was identical (Le Mans: 19.1%; Cagliari: 19.2%); no significant difference was found in unclear-ongoing diagnosis (6.2%; 5.8%) and microalbuminuria (10.5%; 5.8%). Glomerulonephritis and diabetic nephropathy were more frequent in Cagliari (higher age and diabetes prevalence), and interstitial diseases in Le Mans. In the multivariate logistic regression, CKD diagnosis was associated with preterm delivery (adjusted P = 0.035). Gestation was 1 week shorter in patients diagnosed with CKD (Kaplan–Meier P = 0.007). In Cox analysis, CKD remained associated with shorter gestation after adjustment for age and parity. Conclusions The prevalence of newly diagnosed CKD is high after PE (19% versus expected 3% in women of childbearing age), supporting a systematic nephrology work-up after PE.
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Affiliation(s)
| | - Claudia Mannucci
- Nephrology, Centre Hospitalier, Le Mans, France.,Nephrology, University of Pisa, Italy
| | | | | | | | - Sarah Osadolor
- Nephrology, Centre Hospitalier, Le Mans, France.,Medical School of Alberta, Canada
| | - Emily Kimani
- Nephrology, Centre Hospitalier, Le Mans, France.,Medical School of Alberta, Canada
| | | | | | | | | | - Giorgina Barbara Piccoli
- Nephrology, Centre Hospitalier, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Italy
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11
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Jarrick S, Lundberg S, Stephansson O, Symreng A, Bottai M, Höijer J, Ludvigsson JF. Pregnancy outcomes in women with immunoglobulin A nephropathy: a nationwide population-based cohort study. J Nephrol 2021; 34:1591-1598. [PMID: 33683676 PMCID: PMC8494659 DOI: 10.1007/s40620-021-00979-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/22/2021] [Indexed: 01/05/2023]
Abstract
Background Immunoglobulin A nephropathy (IgAN) incidence peaks in childbearing age. Data on pregnancy outcomes in women with IgAN are limited. Methods We performed a register-based cohort study in a nationwide cohort of women with biopsy-verified IgAN in Sweden, comparing 327 pregnancies in 208 women with biopsy-verified IgAN and 1060 pregnancies in a matched reference population of 622 women without IgAN, with secondary comparisons with sisters to IgAN women. Adverse pregnancy outcomes, identified by way of the Swedish Medical Birth Register, were compared through multivariable logistic regression and presented as adjusted odds ratios (aORs). Main outcome was preterm birth (< 37 weeks). Secondary outcomes were preeclampsia, small for gestational age (SGA), low 5-min Apgar score (< 7), fetal or infant loss, cesarean section, and gestational diabetes. Results We found that IgAN was associated with an increased risk of preterm birth (13.1% vs 5.6%; aOR = 2.69; 95% confidence interval [CI] = 1.52–4.77), preeclampsia (13.8% vs 4.2%; aOR = 4.29; 95%CI = 2.42–7.62), SGA birth (16.0% vs 11.1%; aOR = 1.84; 95%CI = 1.17–2.88), and cesarean section (23.9% vs 16.2%; aOR = 1.74, 95%CI = 1.14–2.65). Absolute risks were low for intrauterine (0.6%) or neonatal (0%) death and for low 5-min Apgar score (1.5%), and did not differ from the reference population. Sibling comparisons suggested increased risks of preterm birth, preeclampsia, and SGA in IgAN, but not of cesarean section. Conclusion We conclude that although most women with IgAN will have a favorable pregnancy outcome, they are at higher risk of preterm birth, preeclampsia and SGA. Intensified supervision during pregnancy is warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-00979-2.
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Affiliation(s)
- Simon Jarrick
- Department of Pediatrics, Örebro University Hospital, 701 85, Örebro, Sweden. .,Faculty of Health and Medicine, Örebro University, Örebro, Sweden.
| | - Sigrid Lundberg
- Department of Nephrology, Danderyd Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Adina Symreng
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatisitcs, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Höijer
- Division of Biostatisitcs, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Pediatrics, Örebro University Hospital, 701 85, Örebro, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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12
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Abstract
PURPOSE OF REVIEW We focus on the current understanding of preeclampsia (PE) in order to examine how it mediates glomerular injury and affects the course of glomerulonephritis (GNs). In addition, this review discusses the role of GNs on the development of PE. RECENT FINDINGS In PE, the dysfunctional utero-placental perfusion causes the release into the mother's circulation of anti-angiogenic substances, leading to systemic endotheliosis. In preeclamptic patients, the imbalance between pro- and anti-angiogenic factors is responsible for the kidney injury, and PE may reveal a silent pre-existent GN or may induce the development of the disease. Moreover, in women with chronic kidney disease (CKD), it could accelerate the disease progression. In any case, GNs compromise renal function, making the kidney less responsive to physiological changes that occur during pregnancy and, at the same time, cause maternal vascular inflammation, representing a risk factor for PE development. Although a bidirectional correlation between GNs and PE has been demonstrated, the data are limited, and further large studies are warranted. Close collaboration between a multidisciplinary team of obstetricians and nephrologists is essential to establish the correct diagnosis and safely manage these vulnerable women and their fetuses.
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13
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Vinturache A, Popoola J, Watt-Coote I. The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. J Clin Med 2019; 8:jcm8091396. [PMID: 31500091 PMCID: PMC6780924 DOI: 10.3390/jcm8091396] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (PR-AKI) is a heterogeneous disorder with multiple aetiologies that can occur at any time throughout pregnancy and the post-partum period. PR-AKI is an important obstetric complication that is associated with significant maternal and foetal morbidity and mortality. Although there has been an overall decline in the incidence of PR-AKI worldwide, a recent shift in the occurrence of this disease has been reported. Following improvements in obstetric care, PR-AKI incidence has been reduced in developing countries, whereas an increase in PR-AKI incidence has been reported in developed countries. Awareness of the physiological adaptations of the renal system is essential for the diagnosis and management of kidney impairment in pregnancy. In this review we scrutinize the factors that have contributed to the changing epidemiology of PR-AKI and discuss challenges in the diagnosis and management of acute kidney injury (AKI) in pregnancy from an obstetrics perspective. Thereafter we provide brief discussions on the diagnostic approach of certain PR-AKI aetiologies and summarize key therapeutic measures.
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Affiliation(s)
- Angela Vinturache
- Department of Obstetrics & Gynaecology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK.
| | - Joyce Popoola
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
- Department of Nephrology and Transplantation, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
| | - Ingrid Watt-Coote
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
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14
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Chronic kidney disease in preeclamptic patients: not found unless searched for—Is a nephrology evaluation useful after an episode of preeclampsia? J Nephrol 2019; 32:977-987. [DOI: 10.1007/s40620-019-00629-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022]
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15
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Mitochondrial Disease (MELAS Syndrome) Discovered at the Start of Pregnancy in a Patient with Advanced CKD: A Clinical and Ethical Challenge. J Clin Med 2019; 8:jcm8030303. [PMID: 30836591 PMCID: PMC6462991 DOI: 10.3390/jcm8030303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022] Open
Abstract
Pregnancy is a challenge in the life of a woman with chronic kidney disease (CKD), but also represents an occasion for physicians to make or reconsider diagnosis of kidney disease. Counselling is particularly challenging in cases in which a genetic disease with a heterogeneous and unpredictable phenotype is discovered in pregnancy. The case reported regards a young woman with Stage-4 CKD, in which "Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes" (MELAS syndrome), was diagnosed during an unplanned pregnancy. A 31-year-old Caucasian woman, being followed for Stage-4 CKD, sought her nephrologist's advice at the start of an unplanned pregnancy. Her most recent data included serum creatinine 2⁻2.2 mg/dL, Blood urea nitrogen (BUN) 50 mg/dL, creatinine clearance 20⁻25 mL/min, proteinuria at about 2 g/day, and mild hypertension which was well controlled by angiotensin-converting enzyme inhibitors (ACEi); her body mass index (BMI) was 21 kg/m² (height 152 cm, weight 47.5 kg). Her medical history was characterized by non-insulin-dependent diabetes mellitus (at the age of 25), Hashimoto's thyroiditis, and focal segmental glomerulosclerosis. The patient's mother was diabetic and had mild CKD. Mild hearing impairment and cardiac hypertrophy were also detected, thus leading to suspect a mitochondrial disease (i.e., MELAS syndrome), subsequently confirmed by genetic analysis. The presence of advanced CKD, hypertension, and proteinuria is associated with a high, but difficult to quantify, risk of preterm delivery and progression of kidney damage in the mother; MELAS syndrome is per se associated with an increased risk of preeclampsia. Preterm delivery, associated with neurological impairment and low nephron number can worsen the prognosis of MELAS in an unpredictable way. This case underlines the importance of pregnancy as an occasion to detect CKD and reconsider diagnosis. It also suggests that mitochondrial disorders should be considered in the differential diagnosis of kidney impairment in patients who display an array of other signs and symptoms, mainly type-2 diabetes, kidney disease, and vascular problems, and highlights the difficulties encountered in counselling and the need for further studies on CKD in pregnancy.
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16
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Attini R, Montersino B, Leone F, Minelli F, Fassio F, Rossetti MM, Colla L, Masturzo B, Barreca A, Menato G, Piccoli GB. Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature. J Clin Med 2019; 8:jcm8010123. [PMID: 30669543 PMCID: PMC6352283 DOI: 10.3390/jcm8010123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is increasingly reported in chronic kidney disease (CKD), reflecting higher awareness, improvements in materno-foetal care, and a more flexible attitude towards “allowing” pregnancy in the advanced stages of CKD. Success is not devoid of problems and an important grey area regards the indications for starting dialysis (by urea level, clinical picture, and residual glomerular filtration rate) and for dietary management. The present case may highlight the role of plant-based diets in dietary management in pregnant CKD women, aimed at retarding dialysis needs. The case. A 28-year-old woman, affected by glomerulocystic disease and unilateral renal agenesis, in stage-4 CKD, was referred at the 6th week of amenorrhea: she weighed 40 kg (BMI 16.3), was normotensive, had no sign of oedema, her serum creatinine was 2.73 mg/dL, blood urea nitrogen (BUN) 35 mg/dL, and proteinuria 200 mg/24 h. She had been on a moderately protein-restricted diet (about 0.8 g/kg/real body weight, 0.6 per ideal body weight) since childhood. Low-dose acetylsalicylate was added, and a first attempt to switch to a protein-restricted supplemented plant-based diet was made and soon stopped, as she did not tolerate ketoacid and aminoacid supplementation. At 22 weeks of pregnancy, creatinine was increased (3.17 mg/dL, BUN 42 mg/dL), dietary management was re-discussed and a plant-based non-supplemented diet was started. The diet was associated with a rapid decrease in serum urea and creatinine; this favourable effect was maintained up to the 33rd gestational week when a new rise in urea and creatinine was observed, together with signs of cholestasis. After induction, at 33 weeks + 6 days, she delivered a healthy female baby, adequate for gestational age (39th centile). Urea levels decreased after delivery, but increased again when the mother resumed her usual mixed-protein diet. At the child’s most recent follow-up visit (age 4 months), development was normal, with normal weight and height (50th–75th centile). In summary, the present case confirms that a moderate protein-restricted diet can be prescribed in pregnancies in advanced CKD without negatively influencing foetal growth, supporting the importance of choosing a plant-based protein source, and suggests focusing on the diet’s effects on microcirculation to explain these favourable results.
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Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Benedetta Montersino
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Filomena Leone
- Department of Surgery, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Fosca Minelli
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Federica Fassio
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Maura Maria Rossetti
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Loredana Colla
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Antonella Barreca
- Department of Medical Sciences, University of Torino, 10100 Torino, Italy.
| | - Guido Menato
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Giorgina Barbara Piccoli
- Department of Biological and Clinical Sciences, University of Torino, 10100 Torino, Italy.
- Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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17
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Orozco Guillén AO, Velazquez Silva RI, Moguel González B, Guell YA, Garciadiego Fossas P, Custodio Gómez IG, Miranda Araujo O, Soto Abraham V, Piccoli GB, Madero M. Acute IgA-Dominant Glomerulonephritis Associated with Syphilis Infection in a Pregnant Teenager: A New Disease Association. J Clin Med 2019; 8:jcm8010114. [PMID: 30669309 PMCID: PMC6352144 DOI: 10.3390/jcm8010114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is increasingly recognized as a risk factor in pregnancy; the differential diagnosis between CKD and preeclampsia (PE) may be of pivotal importance for pregnancy management and for early treatment of CKD. Acknowledging this connection may be useful also in a wider context, such as in the case reported in this paper, which for the first time describes an association between syphilis infection and IgA-dominant glomerulonephritis. A 16-year-old woman, referred to a general hospital due to a seizure, was found to be unknowingly pregnant. Based on hypertension and nephrotic proteinuria, she was initially diagnosed with PE. Immunological tests, as well as hepatitis and HIV tests showed negative results. However, secondary syphilis was diagnosed. In discordance with the PE diagnosis, urinalysis showed glomerular microhematuria with cellular casts. Proteinuria and hypertension did not remit after delivery, which was made via caesarean section, due to uncontrolled hypertension, at an estimated gestational age of 29 weeks. A male baby, weighing 1.1 kg (6.5 centile) was born. The baby was hospitalized in the neonatal intensive care unit, where he developed subependymal hemorrhage and thrombocytopenia, and neonatal syphilis was diagnosed. The mother underwent a kidney biopsy one week after delivery, leading to the diagnosis of IgA-dominant postinfectious glomerulonephritis. Mother and child were treated with support and antibiotic therapy, and were discharged in good clinical conditions four weeks later. Four months after delivery, the mother was normotensive without therapy, with normal kidney function and without hematuria or proteinuria. In conclusion, this case suggests that IgA-dominant postinfectious glomerulonephritis should be added to the spectrum of syphilis-associated glomerulonephritides, and underlines the need for a careful differential diagnosis with CKD in all cases of presumed PE. While diagnosis relies on kidney biopsy, urinary sediment, a simple and inexpensive test, can be the first step in distinguishing PE from other nephropathies.
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Affiliation(s)
| | | | - Bernardo Moguel González
- Department of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14080, Mexico.
| | - Yubia Amaya Guell
- Department of Foetal Medicine, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Pamela Garciadiego Fossas
- Department of Infectolog, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Iris Guadalupe Custodio Gómez
- Department of Gynaecology and Obstetrics, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Osvaldo Miranda Araujo
- Department of Gynaecology and Obstetrics, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Virgilia Soto Abraham
- Department of Pathology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14000, Mexico.
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences University of Torino, 10043 Torino, Italy.
- Department of Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Magdalena Madero
- Department of Pathology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14000, Mexico.
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18
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, Liu ZH, Ashuntantang G, Covella B, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. J Clin Med 2018; 7:E415. [PMID: 30400594 PMCID: PMC6262338 DOI: 10.3390/jcm7110415] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | | | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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