Renal disease in pregnancy: Fetal, neonatal and long-term outcomes

Does Delayed Fertility Explain the Rise in Comorbidities Among the Birthing Population?

Background: The increasing prevalence of preexisting health conditions among pregnant people is often attributed to the concurrent rise in maternal age. However, the link between advanced maternal age (AMA) and increases in chronic conditions among the birthing population has not been systematically documented at the population level. Materials and Methods: This retrospective population-based cohort study was based on linked hospitalization discharge and birth certificate data for live birth deliveries in California from 1991 to 2012. Decomposition techniques evaluated whether changes in the prevalence of selected preexisting health conditions during delivery (autoimmune conditions, chronic hypertension, cardiac disease, diabetes, and renal disease) were explained by population-level increases in maternal age. Analyses further adjusted for maternal education, plurality, insurance status, and availability of paternal information on the birth certificate. Results: Between 1991 and 2012, there were more than 11.5 million live birth deliveries in California. AMA (≥35 years) increased nearly 70% over this period. The prevalence of autoimmune conditions, chronic hypertension, diabetes, and renal disease rose among the birthing population, while cardiac disease declined. The prevalence of all conditions was higher for AMA, but changes in maternal age accounted for only 5.3%, 8.4%, 13.9%, and 0.4%, of the increase in autoimmune conditions, chronic hypertension, diabetes, and renal disease, respectively. Conclusion: While AMA was associated with higher rates of preexisting health conditions, it contributed little to the increase in autoimmune conditions, chronic hypertension, and diabetes and nothing to the rise in renal disease during childbirth.

[Outcome of neonates born to mothers with chronic kidney disease]

About 3% of pregnant women suffer from chronic kidney disease (CKD). This article reviews the literature on the outcomes of neonates born to mothers with CKD (including those undergoing dialysis and kidney transplantation), and the results show that CKD during pregnancy may increase the risk of preterm birth, low birth weight, and small for gestational age infant, but it does not increase the risk of congenital anomalies. As for long-term outcomes, CKD during pregnancy has no significant impact on offspring's physical development and immune function. Neurodevelopmental outcome of offspring is associated with preterm birth and low birth weight, rather than intrauterine drug exposure. However, further research and follow-up are needed to investigate the outcome of neonates born to mothers with CKD.

Association between maternal family history of hypertension and preterm birth: modification by noise exposure and multivitamin intake

OBJECTIVE

To measure the effect of maternal family history of hypertension on preterm birth (PTB) and to identify factors that modified this association.

METHODS

A case-control study was nested in a prospective cohort of the entire pregnant population in Wuhan, China, from 2011 to 2013. Home-visit interviews were scheduled for all PTBs and their controls, to collect extensive information on maternal exposures to behavioral, environmental, and intergenerational risk factors of PTB. The effects of maternal family history of hypertension on PTB were measured by logistic regression analyses, controlling for potential confounders. Potential effect modifiers were examined using stratified analyses.

RESULTS

There were 2393 PTBs and 4263 full-term births out of all eligible births. A positive association was observed between maternal family history of hypertension and PTB, after adjusted for potential confounders (adjusted odds ratio: 1.17 [1.03, 1.33]). A higher effect was observed when mothers were exposed to certain noise during pregnancy (adjusted odds ratio: 1.37 [1.14, 1.65]) and/or when they did not take multivitamins during pregnancy (adjusted odds ratio: 1.46 [1.20, 1.78]), whereas, this association was weaker and no longer significant when mothers took multivitamins during pregnancy (adjusted odds ratio: 1.00 [0.84, 1.19]) and/or when they were not exposed to certain noise during pregnancy (adjusted odds ratio: 1.01 [0.85, 1.12]). The modification effect from maternal multivitamin intake was significant on both spontaneous and medically indicated PTBs, and the modification effect from maternal exposure to certain noise was only significant on spontaneous PTB.

CONCLUSIONS

Increased PTB risk was observed for pregnant women with a family history of hypertension in Wuhan, China. This effect was stronger when pregnant women did not take multivitamin and/or exposed to certain noise during pregnancy, than those who took multivitamin and/or unexposed to certain noise.

Recent Advances in the Emerging Therapeutic Strategies for Diabetic Kidney Diseases

Diabetic kidney disease (DKD) is one of the most common causes of end-stage renal disease worldwide. The treatment of DKD is strongly associated with clinical outcomes in patients with diabetes mellitus. Traditional therapeutic strategies focus on the control of major risk factors, such as blood glucose, blood lipids, and blood pressure. Renin–angiotensin–aldosterone system inhibitors have been the main therapeutic measures in the past, but the emergence of sodium–glucose cotransporter 2 inhibitors, incretin mimetics, and endothelin-1 receptor antagonists has provided more options for the management of DKD. Simultaneously, with advances in research on the pathogenesis of DKD, some new therapies targeting renal inflammation, fibrosis, and oxidative stress have gradually entered clinical application. In addition, some recently discovered therapeutic targets and signaling pathways, mainly in preclinical and early clinical trial stages, are expected to provide benefits for patients with DKD in the future. This review summarizes the traditional treatments and emerging management options for DKD, demonstrating recent advances in the therapeutic strategies for DKD.

Parenthood with kidney failure: Answering questions patients ask about pregnancy

Achieving parenthood can be an important priority for women and men with kidney failure. In recent decades, the paradigm has shifted toward greater support of parenthood, with advances in our understanding of risks related to pregnancy and improvements in obstetrical and perinatal care. This review, codesigned by people with personal experience of kidney disease, provides guidance for nephrologists on how to answer the questions most asked by patients when planning for parenthood. We focus on important issues that arise in preconception counseling for women receiving dialysis and postkidney transplant. We summarize recent studies reflecting pregnancy outcomes in the modern era of nephrology, obstetrical, and perinatal care in developed countries. We present visual aids to help clinicians and women navigate pregnancy planning and risk assessment. Key principles of pregnancy management are outlined. Finally, we explore outcomes of fatherhood in males with kidney failure.

Pregnancy Outcomes After Kidney Transplantation and Long-Term Evolution of Children: A Single Center Experience

BACKGROUND

Pregnancies in women who underwent kidney transplants are at high risk compared with the general population.

METHODS

In this study, we aimed to retrospectively assess the obstetrical complications, delivery outcomes, and impact of pregnancy on kidney allograft function in a single-center cohort of kidney transplant recipients (KTRs). We provide data regarding the long-term evolution of children.

RESULTS

Thirty-two KTRs underwent a total of 57 pregnancies between 1994 and 2010. Fourteen pregnancies (24 %) did not survive caused by miscarriages (n = 9), stillborn (n = 1), ectopic pregnancies (n = 2), and medical abortion (n = 2). Live birth occurred in 76% of pregnancies. Delivery was by cesarean in 66%. The mean gestational age was 30.45 ± 11.3 weeks and 65% of newborns were premature. A low birth weight <2500g was noted in 46%. Obstetric complications were de novo hypertension in 4%, pre-eclampsia in 9%, and gestational diabetes in 2%. The 5- and 10-year post-delivery death-censored graft loss rates were 3.1% and 12.5%, respectively. Data on 21 children were collected via a self-questionnaire. After a median follow-up time of 17 years, they appeared in good medical and psychological health. None of them suffered from chronic disease (especially uronephrological condition) or was taking chronic medication.

CONCLUSIONS

Long-term evolution of children born to women who underwent kidney transplants seems favorable. Pregnancies in KTRs are successful in two-thirds of cases but are at increased risk of prematurity, delivery by cesarean, and low birth weight.

Evaluation of obstetric outcomes and prognostic factors in pregnancies with chronic kidney disease

Objective: To evaluate the obstetric outcomes of pregnancies with chronic kidney disease (CKD) and to assess the prognostic factors on adverse obstetric outcomes. Methods: We retrospectively reviewed 101 singleton pregnancies with CKD. Obstetric outcomes were explored according to CKD stages. The composite adverse obstetric outcome was defined as at least one of stillbirth, neonatal death and delivery <34 weeks due to preeclampsia or fetal distress. Results: The incidences of preeclampsia, fetal growth restriction, perinatal mortality and composite adverse obstetric outcome were 40.5%, 26.7%, 14.8% and 37.6% respectively in pregnancies with CKD. Composite obstetric adverse outcome was significantly higher in pregnancies with CKD stage 4-5 than the other stages (p < 0.01). CKD stage 4-5 and baseline proteinuria >3 g/24 h were associated with composite obstetric adverse outcome (OR 43.2, p = 0.005 and OR 6.08, p = 0.01 respectively) comparing to stage 1 and proteinuria <0.5 g/24 h. Conclusion: Incidences of adverse obstetric outcomes are high even in early stages of CKD. CKD stage 4-5 and baseline proteinuria >3 g/24 h are poor prognostic factors.

Neonatal and Maternal Outcomes among Women with Glomerulonephritis

BACKGROUND

The outcomes of pregnancy in women with renal diseases remain controversial. The purpose of the study was to report fetal and maternal outcomes among women with glomerular disease in comparison with healthy pregnant women and a review of the current literature on this issue.

METHODS

Retrospective analysis included 72 pregnancies in 62 women with biopsy-proven glomerulonephritis (GN) (in 65.3% of cases, immunoglobulin A nephropathy was found). The control group consisted of 315 healthy pregnant women. We assessed fetal (prematurity, low birth weight, hypotrophy, fetal malformation, or intrauterine death) and maternal (gestational hypertension, preeclampsia, deterioration in kidney function, and maternal death) outcomes. Descriptive data analysis, Fisher's exact test, unpaired Student's t test, and ANOVA were performed.

RESULTS

Hypertension prevalence among the GN group and controls was 76.4 and 10.2%, respectively. Preeclampsia complicated 29.2% of pregnancies among women with GN and 2.9% of controls. In 8.3% of patients, at least a 50% decrease in GFR during pregnancy was observed. Preterm delivery prevalence in the GN group and controls was 74.7 and 12.7%, respectively. Hypotrophy was diagnosed in 12.5% of cases from the GN group and 5.4% of controls. The analysis showed that low estimated glomerular filtration rate, hypertension, and proteinuria were risk factors of adverse neonatal outcomes.

CONCLUSION

Women with GN are a risk factor of adverse pregnancy outcomes. As pregnancy complications are more prevalent across all the CKD stages, even in patients with near-normal kidney function, they require specialized care. It might be advisable to screen pregnant women for the presence of CKD, as especially in the early stage, it is often asymptomatic. Both hypertension and proteinuria are risk factors for neonatal and maternal complications.

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.

Chronic kidney disease in pregnant mothers affects maternal and fetal disposition of mercury

Chronic kidney disease (CKD) affects over 15 % of the adults in the United States. Pregnant women with CKD present an additional challenge in that they are at increased risk for adverse events such as preterm birth. Exposure to environmental toxicants, such as methylmercury, may exacerbate maternal disease and increase the risk of adverse fetal outcomes. We hypothesized that fetuses of mothers with CKD are more susceptible to accumulation of methylmercury than fetuses of healthy mothers. The current data show that when mothers are in a state of renal insufficiency, uptake of mercury in fetal kidneys is enhanced significantly. Accumulation of Hg in fetal kidneys may be related to the flow of amniotic fluid, maternal handling of Hg, and/or underdeveloped mechanisms for cellular export and urinary excretion. The results of this study indicate that renal insufficiency in mothers leads to significant alterations in the way toxicants such as mercury are handled by maternal and fetal organs.