Renal Disease In Pregnancy Research Articles

Renal disease in pregnancy

Renal disease in pregnancy

The impact of chronic kidney disease on pregnancy

Background. Renal chronic disease can be categorized as an uncommon pathology associated with pregnancy, with a real incidence difficult to estimate. The significant risk for adverse outcomes can be translated into a high degree of occurrence of preeclampsia, fetal growth restriction, preterm delivery, and, also, progression of underlying renal dysfunction. The purpose of the article is to review the data from specialty literature, regarding the correlation between renal function and the pregnancy’s prognosis, so the best management can be implemented to improve the outcomes. Material and methods. We performed a research project conducted in Emergency University Hospital in Bucharest, regarding the impact of chronic renal disease on maternal and fetal outcome. The retrospective and prospective study extends over a period of over 4 years, between 2017 and 2021 and it is currently ongoing with the involvement of the Nephrology Department, the Dialysis Department and the Medical Laboratory. Results. We enrolled 12 pregnant women diagnosed with chronic renal disease. In all cases included in this research the mean 1-minute Apgar Index was 7. The rate of cesarian section was 95%, due to severe preeclampsia in 58% cases, fetal bradycardia in 33.33% cases and placentae abruption in 8.66%. In our study the most frequent risk factor was systemic lupus erythematosus (25%). The risk factors associated with the progression of renal disease in pregnancy were age < 24 years, nephrotic syndrome, hypertension, hematocrit <= 26%, serum creatinine > 1.4 mg/dl, prednisone monotherapy. The blood urea nitrogen had an average of 57 mg/dl, ranging between 26 and 173 mg/dl. Conclusions. The prognosis of pregnancy-associated with renal chronic disease is burdened by the appearance of serious fetal and maternal complications. Thus, special regard should be given to the management of this pathology during pregnancy, so that therapeutic criteria can be easily adopted, taking into consideration that, nowadays, the diagnosis is still a challenge due to the overlapping psychological changes.

Management of Autosomal Dominant Polycystic Kidney Disease (ADPKD) During Pregnancy: Risks and Challenges.

Autosomal dominant polycystic kidney disease (ADPKD) affects up to 1 in 1000 people. The disease is characterized by the progressive development of cysts throughout the renal parenchyma due to inherited pathogenic variants in genes including PKD1 or PKD2 and eventually leads to gradual loss of renal function, along with manifestations in other organ systems such as hepatic cysts and intracranial aneurysms. ADPKD management has advanced considerably in recent years due to genetic testing availability, pre-implantation genetic diagnosis technology and new therapeutic agents. Renal disease in pregnancy is recognised as an important risk factor for adverse maternal and fetal outcome. Women with ADPKD and health professionals face multiple challenges in optimising outcomes during the pre-pregnancy, pregnancy and post-partum periods.

Improving the outcomes for pregnancies in the context of kidney disease

Renal disease in pregnancy is a rare pathology, but it raises several problems in terms of normal pregnancy evolution. Among pregnant women with renal injury, the rate of complications such as spontaneous abortion, preeclampsia, hypertension, intrauterine growth restriction, premature birth, fetal and neonatal mortality are much higher. For a good understanding of the pathology and a correct management of pregnant women with renal disease, it is necessary to know the normal pregnancy changes and the differentiation of chronic kidney disease from the acute injuries occurring during pregnancy. It is useful to ensure counseling prior to conception and to perform all prophylactic measures in order to prevent pregnancy complications and subsequent decline in renal function in all cases of pregnant women with chronic renal insufficiency. Treatment of acute renal failure in pregnancy involves therapy of the underlying condition that caused renal injury, prevention of irreversible kidney injury and pre-vention of maternal and fetal secondary complications. Monitoring carefully this cate-gory of pregnant women, although additional risks strike, often results in favorabl pregnancy evolution.

Clinical practice guideline on pregnancy and renal disease

Background Chronic kidney disease (CKD) is estimated to affect 3% of pregnant women in high-income countries, (Piccoli et al., 2018, #13860) which equates to between 15,000–20,000 pregnancies per year in England. The prevalence of CKD in pregnancy is predicted to rise in the future due to increasing maternal age and obesity. Although CKD is not a barrier to reproduction in most women, the risk of adverse pregnancy outcomes is increased in women with CKD including pre-eclampsia, fetal growth restriction, preterm delivery and accelerated loss of maternal renal function. CKD impacts on communication, decision-making, and the surveillance and management of women before, during, and after pregnancy. Existing guidance on the management of CKD in pregnancy includes the UK Consensus Group on Pregnancy in Renal Disease (ISBN 978–1,107,124,073) and expert review. Neither Kidney Disease Outcomes Quality Initiative (KDOQI) or National Institute of Health and Care Excellence (NICE) have produced specific guidance on the management of renal disease in pregnancy. Published guidance containing information relevant to the care of women with CKD in pregnancy includes: KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). UK Renal Association Commentary available at: BMC Nephrology 2018; 19: 240. KDOQI Clinical Practice Guideline for Haemodialysis, 2015. KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD, 2012 KDIGO Clinical Practice Guideline for Glomerulonephritis, 2012 KDIGO Guideline for the Care of Kidney Transplant Recipients, 2009. KDIGO Clinical Practice Guidelines for Nutrition in Chronic Renal Failure, 2008. NICE: Intrapartum Care for Women with Existing Medical Conditions or Obstetric Complications and their Babies [NG121], 2019. NICE: Urinary Tract Infection (Lower) Antimicrobial Prescribing [NG109], 2018 NICE: Urinary Tract Infection (Recurrent) Antimicrobial Prescribing [NG112], 2018. NICE: Antenatal Care for Uncomplicated Pregnancies [CG62], 2008, updated 2017. NICE: Vitamin D supplement use in specific population groups [PH56], 2017 NICE: Diabetes in Pregnancy: Management from Pre-conception to the Post-partum Period [NG3], 2015. NICE: Antenatal and postnatal mental health: clinical management and service guidance [CG192], 2014, updated 2018. NICE: Fertility: Assessment and Treatment for People with Fertility Problems, 2013. NICE: Weight management before, during and after pregnancy [PH27], 2010 [additional data from 2017 surveillance available at: https://www.nice.org.uk/guidance/ph11/evidence/appendix-a-summary-of-evidence-from-surveillance-pdf-4671107966] NICE: Hypertension in Pregnancy: Diagnosis and Management [CG107], 2011 (update awaited 2019). UK Renal Association Clinical Practice Guidelines: Undernutrition in Chronic Kidney Disease, June 2019 RCOG: Thrombosis and Embolism During Pregnancy and the Puerperium, Reducing the Risk [Green-Top Guideline 37a], 2015. MBBRACE Confidential Enquiry into Maternal Deaths and Morbidity: lessons learned to inform maternity care (triennial reports) www.european-renal-best-practice.org/content/erbp-documents

WITHDRAWN: Preface: Renal disease in pregnancy

WITHDRAWN: Preface: Renal disease in pregnancy

Spotlight on… maternal medicine

When I was asked to do a review of the coverage of maternal medicine in TOG I was unsure what I would find. Have we covered the breadth of the subject? Have we concentrated in the obvious areas? Are the articles all written by leaders in their field or by trainees hoping to get a foothold on their climb towards academic achievement? The first article on maternal medicine appeared in TOG volume 1 1999 (TOG 1999;1:29–32). Written by one of the founders of maternal medicine in the UK, John Davison, it was an educational article on chronic renal disease in pregnancy. Whilst the field has moved on in the last 16 years, this well written article is an excellent introduction to the subject. The first article on hypertension in pregnancy was published in 2003 (TOG's 5th year). Written by Glanville and Walker (TOG 2003;5:149–154) this remains an authoritative description of HELLP, its pathogenesis and management (albeit they did not know about the beneficial affects of magnesium for the premature baby). Over the years there have been another five articles on hypertension and, taken as a whole, these give a comprehensive guide on the pathophysiology and management of hypertension in pregnancy and the puerperium. One of the most recent was a scholarly and comprehensive discussion on the use of aspirin (and calcium) in the prevention of pre-eclampsia (TOG 2014;16:245–250). As we have improved the care of pregnant women, cardiac disease has risen to be the commonest cause of maternal death. The importance of this is reflected in an article by Wuntaakal et al. (TOG 2013;15:247–255) on myocardial infarction in pregnancy and a pair of articles by Gelson et al. (TOG 2007;9:15–20 and TOG 2007;9:83–87) on acquired and congenital heart disease. This pair of articles elegantly describes the complex multidisciplinary care these women require and the excellent results that can be achieved. Sepsis has featured heavily in maternal mortality statistics in recent years with a peak in deaths from Group A Streptococcus in the 2006–8 triennium and sepsis accounting for 1 in 4 of all maternal deaths in the 2009–2012 report (MBBRACE 2014). This area has been covered with articles on appendicitis (TOG 2015;17:105–110), genital tract sepsis (TOG 2012;14:106–114) and Group A Streptococcus (TOG 2012;14:9–16). Through this series of articles, TOG has taken a lead in ensuring that clinicians are informed and may help in the campaign to control sepsis. Of all the UKOSS updates published over the years, the most influential was in 2011 during the H1N1 season. Marian Knight's short article (TOG 2011;13:63) on AH1N1 influenza in pregnancy brought home to many the dangers of influenza in pregnancy, the possible role of timely anti-viral treatment and the importance of the influenza vaccine. Then there are the less serious but common conditions that bother all obstetricians such as headache in pregnancy and asthma in pregnancy. Revell and Morrish (TOG 2014;16:179–184) describe how to differentiate between common and serious causes of headaches in pregnancy with a helpful discussion of ‘red flag’ symptoms. Goldie and Brightling (TOG 2013;15:241–245) bring us up-to-date with treatments of asthma, how to reduce the risk of exacerbation and the role of modern treatments, such as montelukasts. Mental health disorders are not ignored with articles on anorexia nervosa (TOG 2012;14:179–187), postnatal affective disorders (TOG 2008;10:231–235) and maternal depression (TOG 2008;10:151–155). This is just a taste of the over 30 articles on maternal disease in pregnancy that have appeared in TOG in the last 15 years. I recommend them to all obstetricians, GPs with an interest in improving maternal health and our midwifery colleagues. Along with the regular updates from UKOSS, summaries of RCOG Green-top Guidelines, and release of key messages from MBBRACE (released online in TOG on the day of the release of the data in December 2014 [TOG 2015;17: 72–73]), TOG is leading the way in helping obstetricians across the world improve maternal outcomes. A virtual issue of all TOG articles on maternal medicine is available at http://onlinetog.org.

Chronic kidney disease in pregnancy: Maternal and fetal outcomes and progression of kidney disease

There is a paucity of Australian data regarding renal disease in pregnancy. We undertook a retrospective cohort study at a tertiary institution to examine the impact of renal disease on pregnancy outcomes and the effect of pregnancy on disease progression. A total of 55 pregnancies of patients with renal disease admitted from 2003 to 2010 to the Royal Brisbane and Women's Hospital were analysed. Pre-conception variables, fetal/delivery and maternal outcomes were analysed in this group and in a control group of women with normal kidney function pre-pregnancy. Of the 55 pregnancies, 71% experienced pre-term delivery, 38% had intra-uterine growth restriction and 62% required caesarean section. Of all, 60% of neonates required neonatal intensive care unit (NICU) admission and six perinatal deaths occurred. Of all, 67% of women suffered preeclampsia, 47% anaemia and 3 patients required dialysis in pregnancy. Postpartum deterioration of renal function occurred in patients with pre-conception chronic kidney disease stage 3-5. Chronic kidney disease of all stages is a risk factor for adverse pregnancy outcomes. In a tertiary institution however, there is a high rate of successful pregnancy (84%).

Pregnancy and the kidneys.

Renal disease in pregnancy may cause a feeling of trepidation, even in the most experienced physician. However, before disease can be established, it is important to understand the substantial physiological changes that may occur during a normal pregnancy. Renal disease may take several forms and pregnancy may be the first medical review for women with a previously undiagnosed renal problem. Patients may have pre-existing renal disease, e.g. diabetic nephropathy. Additionally, women with renal transplants and renal diseases, e.g. lupus nephritis, require immunosuppression. Hypertensive disorders of pregnancy, including pre-eclampsia, are the commonest medical complications in pregnancy, and remain the most prevailing direct cause of maternal mortality in South Africa (SA). Both pre-existing hypertension and renal disease increase the risk of pre-eclampsia, which predisposes to preterm delivery, and maternal morbidity and mortality. Pregnancy outcomes in renal disease are determined by baseline creatinine levels, hypertension and degree of proteinuria. The risk of progression of chronic kidney disease increases as renal function worsens. In SA, this is complicated by restricted access to dialysis in the state sector. To ensure the best outcome for mother and child, pre-pregnancy counselling and review of medication are essential. Renal patients and those with hypertension are at high risk of complications, and regular antenatal assessments by a multidisciplinary team are required to monitor blood pressure, proteinuria, diabetes control and fetal wellbeing.

Contemporary Uses of Erythropoietin in Pregnancy

The objectives of this study were to survey the current research and provide an update on the uses and benefits of erythropoietin (EPO) in pregnancy and the postpartum period. A review of MEDLINE (1947 to present) was performed. Search terms included "erythropoietin," "pregnan*," with subheadings of "administration & dosage," "pharmacokinetics," "therapeutic use," "fetus," "fertility." We reviewed relevant articles published from 2002 to 2012. Case reports, observational studies, case-control studies, randomized controlled trials, retrospective analyses, animal studies, and review articles were included. Articles were selected if they discussed a use of EPO in pregnancy or the immediate postpartum period, as well as use of EPO in the neonate. Authors independently reviewed and extracted data. Of the 65 articles reviewed, 45 were included. Erythropoietin was used in the treatment of maternal anemia. Because of the molecule's large size, recombinant EPO does not appear to cross the placenta. No fetal morbidity or mortality was noted. Therefore, this is a safe therapy that can be used in pregnancy. Use of EPO may be especially important for women who decline blood products. Neonatal uses of EPO show benefit in the treatment of anemia due to blood type incompatibility. Erythropoietin is gaining popularity as a therapeutic option during pregnancy and the postpartum period. Further investigation is needed to establish a standard dosage and dosing interval. New studies reviewing its use in the neonate for perinatal-hypoxic injury and anemia due to blood type incompatibility provide exciting opportunities for further therapeutic use. Obstetricians and gynecologists, family physicians. After completing this CME activity, physicians should be better able to treat anemia in pregnancy, including causes and interventions; assess renal disease in pregnancy, targets of hemoglobin, precautions, and treatment considerations; and evaluate erythropoietin use in neonates and fetuses, including benefits, complications, and areas for upcoming research/uses.

PP025. Measurement of the activity of the circulating and intrarenal renin–angiotensin system (iRAS) in pregnant and non-pregnant subjects

To see if urinary angiotensinogen (uAGT)/creatinine and other urinary components of the RAS could be used to detect renal disease in pregnancy, as renal disease predisposes to preeclampsia. Plasma and urinary prorenin, ACE and AGT (iRAS) were measured by ELISA. Urinary active renin levels were measured enzymatically (9 males, 10 non pregnant, 61 Australian Indigenous pregnant women). No relationships between plasma RAS and iRAS were found. In non-pregnant females plasma AGT levels were inversely related to protein and albumin/creatinine (r=-0.72, P=0.019, n=10; r=-0.65, P=0.042, n=10). In pregnancy, plasma ACE levels were related to protein/creatinine (r=0.29, P=0.036, n=54). Urinary protein/creatinine was not related to iRAS activity (males and non-pregnant females) but in pregnancy was related to prorenin and active renin/creatinine (r=0.45, P=0.02, n=26 r=0.47, P<0.001, n=50). Urinary albumin/creatinine was related to uAGT and active renin/creatinine in pregnancy (r=0.39, P=0.005, n=51; r=0.37, P=0.008, n=51). uACE/creatinine and uAGT/creatinine were related (r=0.52, P<0.001, n=51). Excretion of components of the iRAS is independent of plasma levels. Not only is uAGT/creatinine related to albumin/creatinine but there are similar relationships with other iRAS components. Measurement of the iRAS in human pregnancy may detect early stage renal disease, endemic in Indigenous Australians.

Contraception for renal transplant recipients in the Republic of Ireland : a review

Renal transplantation has extended the duration and quality of life for a growing number of women in the Republic of Ireland. Pregnancy has now become a reasonable and viable option for women who were previously too ill to conceive, leading the Royal college of Obstetricians and Gynaecologists to issue opinions on the management of women with renal disease in pregnancy. In the 10-year period, from 2000 to 2009, 1,412 renal transplants were undertaken at Beaumont Hospital, Dublin. Of these, 541 were female patients and 333 of these women were in the reproductive age group (18-49years) and thus would have potentially required some method of contraception. Improvements in overall health can lead to an early return to fertility and menstruation following renal transplant. It is recommended that the optimal management after renal transplantation is to ensure graft stability and optimal function before pregnancy is considered. It is also advisable to titrate immunosuppressive medication to the lowest maintenance dose possible to minimise potential fetal effects. Thus, a duration of 1year post-living donor renal transplant and 2years post-cadaveric donor transplant is usually quoted before embarking on a pregnancy, although this may vary from case to case. Women of reproductive age undergoing renal transplantation have a need for highly effective contraception. This review provides an overview of methods available in the Republic of Ireland and the evidence for their use in renal transplant recipients.

Renal disease in pregnancy

Pregnancy in women with chronic kidney disease (CKD) is associated with risks of accelerated decline in renal function in the mother and adverse outcomes for the infant, including prematurity and growth restriction. Managing these risks requires collaboration between patient, nephrologist, neonatologist and obstetrician. In this review we will discuss approaches to managing pregnancy in women with CKD.

Chronic renal disease in pregnancy: obstetric outcomes and effect of pregnancy on renal function

IntroductionChronic renal impairment is associated with adverse obstetric outcomes including pre-eclampsia, prematurity and intra-uterine growth restriction. Pregnancy can accelerate decline in renal function: degree of deterioration is dependent on pre-pregnancy...

Angiogenic Factors and Renal Disease in Pregnancy

Background. Preeclampsia is difficult to diagnose in patients with underlying renal disease and proteinuria. Prior studies show that there is an angiogenic factor imbalance with elevated levels of antiangiogenic proteins soluble fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (sEng) and reduced levels of the proangiogenic protein, placental growth factor (PlGF) in women with preeclampsia. These angiogenic biomarkers may be useful in distinguishing preeclampsia from other conditions of pregnancy, which may present with overlapping clinical characteristics. Cases. Case 1: A multiparous woman at 18 weeks gestation with nephrotic syndrome presented with hypertensive emergency and worsening renal insufficiency. She underwent induction of labor for severe preeclampsia. Her sFlt1 and sEng levels were at the 97 percentile while her PlGF level was undetectable (less than the 1st percentile). Case 2: A nulliparous woman with lupus nephritis at 22 weeks gestation presented with fetal demise and heart failure. Three weeks previously, the patient had developed thrombocytopenia and hypertensive urgency. She underwent dilation and evacuation. Her angiogenic profile was consistent with severe preeclampsia. Conclusion. Angiogenic factors may provide evidence to support a diagnosis of preeclampsia in patients with preexisting renal disease and proteinuria, conditions in which the classical definition of hypertension and proteinuria cannot be used.

Renal disease in pregnancy

Kidney disease in pregnancy is rare but associated with considerable risks of adverse maternal and foetal outcomes, and considerable anxiety on the part of the clinician. Evidence based strategies for management are limited. In this review we will discuss current trends in monitoring, treatment and prognosis for patients with chronic kidney disease, end-stage kidney disease and acute kidney injury in pregnancy.

Renal Disease in Pregnancy

Renal disease in pregnancy has historically been an area of controversy and discomfort for many nephrologists and obstetricians. Women with renal disease are clearly at increased risk of fetal and maternal complications and, in the past, were dissuaded from attempting to become pregnant. However, attitudes have changed and chronic kidney disease (CKD) is no longer considered an absolute contraindication to pregnancy. Today, pregnancy in the setting of renal disease is becoming more common. As mentioned in Chapter 2, between 3% and 10% of women of child-bearing age might be defined as having CKD when using the estimation of glomerular filtration rate rather than serum creatinine to assess renal function.1

Management of women with chronic renal disease in pregnancy

A multidisciplinary team should manage pregnancy in women with chronic renal disease. The outcome is dependent upon prepregnancy renal function and the presence of hypertension and proteinuria. Women on dialysis and renal transplant recipients form a special group that needs expert care during pregnancy. Learning objectives: To understand the basic principles in prepregnancy counselling of women with chronic renal disease. To be aware of the risks to the pregnancy as well as to long‐term renal function. Ethical issues: The risks of serious complications and adverse effects on long‐term health raise complex ethical issues for the health professionals who counsel women with chronic renal disease and look after them during pregnancy. Please cite this article as: Kapoor N, Makanjuola D, Shehata H. Management of women with chronic renal disease in pregnancy. The Obstetrician &amp; Gynaecologist 2009;11:185–191.

Renal disease in pregnancy

Journal of Renal NursingVol. 4, No. 4 guest editorialRenal disease in pregnancyCatherine Nelson-PiercyCatherine Nelson-PiercySearch for more papers by this authorCatherine Nelson-PiercyPublished Online:29 Sep 2013https://doi.org/10.12968/jorn.2012.4.4.168AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesBramham K, Duncan N, Lightstone L et al. (2010) Pregnancy in kidney-pancreas transplant recipients: report of three cases and review of the literature. Obstet Med 3(2): 73–77 Crossref, Google ScholarNational Institute for Health and Clinical Excellence (2010) Hypertension in Pregnancy: the Management of Hypertensive Disorders during Pregnancy. http://guidance.nice.org.uk/CG107/Guidance/pdf/English (accessed 21 June 2012) Google ScholarWilliams D, Davison J (2008) Chronic kidney disease in pregnancy. BMJ 336(7637): 211–5 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 July 2012Volume 4Issue 4ISSN (print): 2041-1448ISSN (online): 2052-2894 Metrics History Published online 29 September 2013 Published in print 1 July 2012 Information© MA Healthcare LimitedPDF download

Pregnancy in chronic renal insufficiency: single centre experience from North India

Renal disease during pregnancy is relatively uncommon. The diagnosis of renal disease before or during pregnancy was only 0.03% in a population-based study of pregnant women with kidney disease. However, there is a paucity of scientific data regarding the general topic of renal disease in pregnancy on which to base clinical management and counselling recommendations. A retrospective analysis of 14 year period was carried out in a referral hospital in northern India. Pregnant women were analyzed with respect to degree of renal impairment for the effect of renal disease on course of pregnancy, complications during pregnancy and perinatal outcome. Outcome of 30 pregnancies (29 women) was available during the study period of 14 years. Pregnancy outcome was comparable in all types of glomerulonephritis. Progression of the disease during pregnancy was observed in total six patients. Proteinuria was in the range of 800 mg/day to 6.2 g/day (2.802 +/- 1.519 g/day). Anemia was identified in 12(46.1%) and 3(7.7%) required multiple blood transfusions. Twenty-four (90%) women developed hypertension during pregnancy. Mild hypertension was seen in 40% patients and, 43.3% had severe hypertension requiring drug therapy. Obstetrical complications included a high frequency of preterm delivery (85%) and caesarean section (30%). Overall fetal survival rate was 77%. Most women with chronic renal disease will have a successful outcome if they receive proper prenatal care. Pregnant women with moderate or severe renal insufficiency have increased rates of complications due to worsening renal function, hypertension, and other obstetrical complications, but fetal survival is high.