Antecedent renal disease and the outcome of pregnancy

A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy

BACKGROUND AND OBJECTIVES

We undertook a systematic review and meta-analysis of published cohort studies and case-control studies to estimate (1) the risk of pregnancy complications among patients with CKD versus those without CKD and (2) the risk of CKD progression among pregnant patients versus nonpregnant controls with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched electronic databases for studies published between 1946 and 2014, and we reviewed articles using validity criteria. Random-effects analytical methods were used.

RESULTS

Twenty-three studies (14 with data for adverse pregnancy outcomes and 9 for renal outcomes) with 506,340 pregnancies were included. Pregnancy with CKD had greater odds of preeclampsia (odds ratio [OR], 10.36; 95% confidence interval [95% CI], 6.28 to 17.09), premature delivery (OR, 5.72; 95% CI, 3.26 to 10.03), small for gestational age/low birth weight (OR, 4.85; 95% CI, 3.03 to 7.76), cesarean section (OR, 2.67; 95% CI, 2.01 to 3.54), and failure of pregnancy (OR, 1.80; 95% CI, 1.03 to 3.13). Subgroup analysis showed that odds of preeclampsia (P<0.01) and premature delivery (P<0.01) were higher in women with nondiabetic nephropathy compared with diabetic nephropathy, and the odds of preeclampsia (P=0.01) and premature delivery (P<0.01) were higher in women with macroproteinuria compared with microproteinuria. The median for follow-up time for renal events was 5 years (interquartile range, 5-14.7 years). There were no significant differences in the occurrence of renal events between CKD pregnant women and those without pregnancy (OR, 0.96; 95% CI, 0.69 to 1.35). Subgroup analysis showed that publication year, sample size, follow-up years, type of primary disease, CKD classification, level of serum creatinine at baseline, proteinuria, and level of systolic BP did not modify the renal outcomes.

CONCLUSIONS

The risks of adverse maternal and fetal outcomes in pregnancy are higher for women with CKD versus pregnant women without CKD. However, pregnancy was not a risk factor for progression of renal disease in women with CKD before pregnancy.

Kidney disease and maternal and fetal outcomes in pregnancy

BACKGROUND

Pregnancy in kidney disease is considered high risk, but the degree of this risk is unclear. We tested the hypothesis that kidney disease in pregnancy is associated with adverse maternal and fetal outcomes.

STUDY DESIGN

Retrospective study comparing pregnant women with and without kidney disease.

SETTING & PARTICIPANTS

Using data from an integrated health care delivery system from 2000 through 2013, a total of 778 women met the criteria for kidney disease. Using a pool of 74,105 women without kidney disease, we selected 778 women to use for matches for the women with kidney disease. These women were matched 1:1 by age, race, and history of diabetes, chronic hypertension, liver disease, and connective tissue disease.

PREDICTOR

Kidney disease was defined using the NKF-KDOQI definition for chronic kidney disease or International Classification of Diseases, Ninth Revision codes prior to pregnancy or serum creatinine level > 1.2mg/dL and/or proteinuria in the first trimester.

OUTCOMES & MEASUREMENTS

Maternal outcomes included preterm delivery, delivery by cesarean section, preeclampsia/eclampsia, length of stay at hospital (>3 days), and maternal death. Fetal outcomes included low birth weight (weight < 2,500g), small for gestational age, number of admissions to neonatal intensive care unit, and infant death.

RESULTS

Compared with women without kidney disease, those with kidney disease had 52% increased odds of preterm delivery (OR, 1.52; 95% CI, 1.16-1.99) and 33% increased odds of delivery by cesarean section (OR, 1.33; 95% CI, 1.06-1.66). Infants born to women with kidney disease had 71% increased odds of admission to the neonatal intensive care unit or infant death compared with infants born to women without kidney disease (OR, 1.71; 95% CI, 1.17-2.51). Kidney disease also was associated with 2-fold increased odds of low birth weight (OR, 2.38; 95% CI, 1.64-3.44). Kidney disease was not associated with increased risk of maternal death.

LIMITATIONS

Data for level of kidney function and cause of death not available.

CONCLUSIONS

Kidney disease in pregnancy is associated independently with adverse maternal and fetal outcomes when other comorbid conditions are controlled by matching.

Pregnancy outcomes in women with chronic kidney disease: a systematic review

BACKGROUND AND OBJECTIVES

Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis.

RESULTS

We identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without.

CONCLUSIONS

This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.

The possible role of F-18 FDG positron emission tomography in the differential diagnosis of focal pancreatic lesions

PURPOSE

To compare the diagnostic values of different methods for the differentiation of malignant from benign pancreatic lesions.

METHODS

In 22 patients with focal pancreatic lesions, the carbohydrate antigen (CA) 19-9 level was measured; abdominal ultrasound (US), computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) were performed; and the value of these methods were analyzed for their use in cancer diagnosis.

RESULTS

Malignant lesions were identified in six patients and verified by surgery or clinical follow-up. The CA 19-9 level was elevated in four of the five patients examined (sensitivity, 80%). In all six cases, US and CT revealed hypoechogenic and hypodense areas (sensitivity, 100%). In one patient, ERCP was unsuccessful but yielded true-positive results in three others (sensitivity, 60%). The sensitivity of FDG PET was 100%. Sixteen focal cases of pancreatic disease proved to be benign. The CA 19-9 level was elevated in four of them (specificity, 73%). Hypoechogenic and hypodense areas were evident on US and CT in eight patients. The specificity of CT was 50% (8 of 16 cases). The specificity of US was 47% (7 of 15 cases). The specificity of successful ERCP was 92%. Fourteen negative FDG-PET results were truly negative. In two patients, however, the PET findings proved to be falsely positive (specificity, 88%).

CONCLUSIONS

FDG-PET is an effective tool to differentiate malignant from benign focal pancreatic lesions. In persons with focal pancreatic hypoechogenic or hypodense lesions detected by CT or US and an elevated CA 19-9 level, FDG PET should be the next step in the diagnostic strategy.

MOS HIP: McMaster outcome study of hypertension in pregnancy

BACKGROUND

The offspring of women with hypertension during pregnancy are at increased risk of low birthweight, preterm birth, diseases of prematurity and death. The risk of developing these outcomes among women with either preeclampsia or chronic hypertension, relative to those with gestational hypertension, is not known.

STUDY DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1948 singleton women seen at a large tertiary care obstetrical center, whose blood pressure was greater than 140/90 mm Hg during pregnancy. The four types of hypertension were strictly defined: 864 women (44.4%) had gestational hypertension, 459 (23.6%) isolated chronic hypertension, 501 (25.7%) isolated preeclampsia, and 124 (6.4%) chronic hypertension with superimposed preeclampsia.

OUTCOME MEASURES

The primary outcome of the study was a composite of the diseases of prematurity, need for assisted ventilation for greater than 1 day, or perinatal death. The secondary outcomes were each of those included in the primary endpoint, as well as admission to the neonatal ICU, small for gestational age (SGA) birthweight and preterm birth. We controlled for the effects of other maternal risk factors, such as age, parity, history of preterm delivery, cigarette smoking, pre-pregnancy weight, diabetes mellitus (DM), renal dysfunction, and current use of an antihypertensive agent or prednisone.

RESULTS

For the primary composite outcome, compared to the offspring of women with gestational hypertension, the adjusted odds ratio was 1.9 (95% confidence interval 1.2 to 3.0) in the preeclamptic group and 2.0 (95% confidence interval 1.0 to 4.0) for those with chronic hypertension plus superimposed preeclampsia. Those with preeclampsia were at increased risk for small for gestational age birthweight (odds ratio 2.2, 95% confidence interval 1.5 to 3.1), as were the offspring of mothers who had chronic hypertension with superimposed preeclampsia (odds ratio 2.1, 95% confidence interval 1.2 to 3.8). Similarly, the rate of preterm birth before 32 weeks was highest among the infants of both preeclamptic mothers (28.5%; odds ratio 4.7, 95% confidence interval 2.9 to 7.6) and those with chronic hypertension and preeclampsia (30.5%; odds ratio 3.5, 95% confidence interval 1.8 to 6.7). The perinatal mortality rate was highest in the group of women with chronic hypertension plus preeclampsia (9.2%; odds ratio 3.2, 95% confidence interval 1.2 to 9.1). Other significant risk factors for the primary composite outcome included previous preterm delivery (odds ratio 2.7, 95% confidence interval 1.4 to 5.2), smoking (odds ratio 1.8, 95% confidence interval 1.1 to 3.0) and use of an antihypertensive agent during pregnancy (odds ratio 1.8, 95% confidence interval 1.2 to 2.7). Prednisone use was strongly associated with risk for perinatal death (odds ratio 4.9, 95% confidence interval 1.4 to 17.1).

CONCLUSIONS

Relative to women with isolated gestational hypertension, those who develop preeclampsia, either with or without underlying chronic hypertension, experience worse perinatal outcomes. A history of previous preterm delivery and maternal smoking increase the rate preterm birth and major perinatal disease. Antihypertensive and prednisone therapy may be important risk factors for adverse perinatal events, but further research is needed to confirm these findings.

Effect of pregnancy on moderate renal failure in reflux nephropathy

During a 10 year study of women with reflux nephropathy 20 women had plasma creatinine concentrations in the range 0.2-0.4 mmol/l (2.3-4.5 mg/100 ml). Six experienced pregnancies exceeding 12 weeks' gestation. Pregnancy was associated with rapid deterioration in function in all six, resulting in end stage renal failure in four women within two years after delivery despite adequate control of blood pressure. Of the 14 women who did not have a prolonged pregnancy, four had periods of uncontrolled hypertension, all of which were related to non-compliance or loss from follow up, or both. Uncontrolled hypertension was also associated with accelerated renal failure, and all four women progressed quickly to end stage renal failure. The remaining 10 women were observed for from five to 10 years; in all 10 renal function deteriorated slowly, and none reached end stage renal failure within seven years. It is concluded that pregnancy in patients with reflux nephropathy and moderately severe renal failure has a deleterious effect on renal function.