P97. Chronic kidney disease and pregnancy – A case report

Abstract

Introduction Chronic kidney disease (CKD) is classified in five stages. Perinatal complications, such as preterm labor, preeclampsia and fetal growth restriction (FGR) are increased for all stages. In women with serum creatinine (sCr) above 2.5 mg/dL, the rate of preterm delivery is as high as 86%, mainly due to preeclampsia, which occurs in over 40%. The degree of renal insufficiency, rather than the underlying etiology, is the primary determinant of outcome. Women who become pregnant with high sCr level, are more likely to have a decline in renal function, than women who do not become pregnant, for the same sCr level. Hypertension and degree of proteinuria are also among the most important predicting factors. Fifty percent of women with sCr >1.5 mg/dL have a significant decline in glomerular filtration rate (GFR) in late pregnancy or early postpartum, with 20% of them progressing to end-stage renal disease (ESRD) within 6 months after delivery. Methods Review of literature about CKD and pregnancy and presentation of a clinical case. Results A 37-year-old African female, G3P1, engaged prenatal care at our hospital at 13 weeks gestation, with CKD – stage 4 (estimated GFR of 20.2 mL/min), for a baseline sCr level of 3.3 mg/dL. She had a nephrotic syndrome at 9 years old. Renal biopsy revealed diffuse mesangial proliferative glomerulonephritis, and was treated with prednisolone and cyclophosphamide. It progressed to CKD with secondary hypertension, treated with enalapril and amlodipine. During pregnancy she was medicated with methyldopa, amlodipine, darbepoetin, vitamin D, vitamin B, ferrous sulfate and calcium. Routine workup at 26 weeks revealed sCr 3.57 mg/dL, uric acid 9.4 mg/dL, without proteinuria. Pregnancy was uneventful until 34 weeks gestation, when she was admitted to with preeclampsia and worsening renal function. At admission, sCr 5.11 mg/dL, urea 174 mg/dL, uric acid 9.55 mg/dL and spot urine protein level of 200. Ultrasound revealed FGR (1st percentile), with altered Doppler velocimetry that motivated urgent cesarean delivery. The newborn weight was 1340g, female, Apgar score 10/9/10. At day 7 postpartum, she was discharged from the hospital, with sCr 5.34 mg/dL, urea 211 mg/dL and proteinuria 4+. Hemodialysis was programmed, as she awaits a donor for renal transplant. Conclusion Although pregnancy in women with CKD is associated with a high rate of live births, it is usually complicated by preeclampsia and fetal growth restriction. The higher the stage of CKD, the greater the probability of postpartum deteriorated renal function, with a significant proportion of women progressing to ESRD.