Pregnancy and Chronic Kidney Disease

Pre-gestational counselling for women living with CKD: starting from the bright side

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Becoming a mother when suffering from a chronic illness

INTRODUCTION

The critical period of early motherhood when facing serious health problems constitutes a major public health issue. The disease may interfere with, influence, and compound the difficulties experienced over the course of pregnancy and during the parenthood processes. These processes are to be understood as a passage involving so many changes and fraught with difficulties leading to a series of psychological mobilizations. Illness also needs to be considered as a moment of transition, sometimes of severance, marking the lives of the people concerned in a more or less lasting way. Various developments are possible, some of which can be envisaged as leading to more positive outcomes, while others appear as if blocked or doomed to failure.

CLINICAL DATA AND METHOD

This clinical study is the result of twelve analytically oriented psychotherapeutic follow-ups. The sessions took place weekly over periods ranging from 1 to 6 years. Some of the patients we met had become pregnant while they had a declared but not yet chronic nephropathy. The other patients were already on dialysis and had become mother before starting dialysis. There is also one instance of a pregnant patient on dialysis. In the background, there are also many women who talked about giving up fertility and motherhood. After an in-depth study of each follow-up, a cross-sectional study was conducted to identify the main themes.

RESULTS AND DISCUSSION

Main considerations on the psychotherapeutic treatment: We regularly observe people who find it impossible to muster the internal resources that would enable them to deal with the trials they undergo in such situations. For the psychologist, there is a need to listen to archaic remnants. Gradually, in the space of psychotherapeutic work, possibilities of "reanimation" of the psyche emerge, an internal space that renews fantasmatic activity as it begins to be able to project into the external space and into the space of the sessions.

Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease

The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.

Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease

Pregnancy requires several physiological adaptations from the maternal organism, including modifications in the glomerular filtration rate and renal excretion of several products. Chronic kidney disease (CKD) can negatively affect these modifications and consequently is associated with several adverse maternal and fetal adverse outcomes (gestational hypertension, progression of renal disease, pre-eclampsia, fetal growth restriction, and preterm delivery). A multidisciplinary vigilance of these pregnancies is essential in order to avoid and/or control the harmful effects associated with this pathology. Dialysis and transplantation can decrease the risks of maternal and fetal complications, nonetheless, the rates of complications remain high comparing with a normal pregnancy. Several recent developments in this area have improved quality and efficacy of treatment of pregnant women with CKD. This article summarizes the most recent literature about CKD and pregnancy.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Transfer of uremic solutes across the human term placenta: An ex vivo study in the dual-side perfused cotyledon

INTRODUCTION

An increasing number of women becomes pregnant while suffering from chronic kidney disease (CKD). As a result of decreased renal function, uremic solutes circulate at high levels in the maternal circulation. This study aimed to acquire more knowledge about the placental transfer of uremic solutes across the human placenta.

METHODS

Placental transfer was studied in healthy term placentas, via the ex vivo dual-side human cotyledon perfusion technique (closed-closed set-up for both maternal and fetal circulations). Uremic solute concentrations in maternal and fetal perfusates were measured via LC-MS/MS over 180 min of perfusion.

RESULTS

We found that the studied compounds demonstrated different degrees of placental transfer. Fetal-to-maternal perfusate ratios at t = 180 min were for anthranilic acid 1.00 ± 0.02, indole-3-acetic acid 0.47 ± 0.08, hippuric acid 0.36 ± 0.18, l-arabinitol 0.33 ± 0.04, indoxyl sulfate 0.33 ± 0.11, neopterin 0.28 ± 0.14 and kynurenic acid 0.13 ± 0.03. All uremic solutes studied also emerged in the perfusates when cotyledons were perfused in the absence of uremic solute concentrations added to the maternal reservoir. For kynurenin these concentrations were so high, it complicated the calculation of a transfer ratio for the exogenously administered compound.

DISCUSSION

After 180 min of exposure the extent of placental transfer differs substantially for the solutes studied, reflecting different transfer rates. Future studies should investigate to what extent specific uremic solutes reach the fetal circulation in vivo and how they may interfere with organ function and development of the unborn child.

Association of Serum PSP/REG Iα with Renal Function in Pregnant Women

Pancreatic stone protein/regenerating protein Iα (PSP/REG Iα) is a secretory protein produced in the pancreas, but its expression has also been observed in the kidney. It may be associated with kidney dysfunction. This study investigates the possible association between PSP/REG Iα and kidney function in pregnant women. Serum PSP/REG Iα levels were measured by a specific ELISA enzyme-linked immunosorbent assay. Maternal information and clinical and biochemical parameters were collected. Estimated glomerular filtration rate (eGFR) was calculated for all individuals to evaluate their renal function. Spearman's correlation and multiple linear regression analyses were performed to assess the associations between PSP/REG Iα and eGFR, serum creatinine (Cr), blood urea nitrogen (BUN), and uric acid (UA). A total of 595 pregnant women were enrolled in the study. Participants with mildly reduced eGFR had higher PSP/REG Iα levels [50.49 (35.02, 58.64)] than in the general population [26.84 (21.02, 33.07)] (p < 0.001). Included participants were stratified into PSP/REG Iα quartiles; significant differences were observed in the levels of eGFR, serum Cr, BUN, and UA. PSP/REG Iα was negatively correlated with eGFR (r = -0.402, p < 0.001) and positively associated with serum Cr (r = 0.468, p < 0.001), BUN (r = 0.166, p < 0.001), and UA (r = 0.207, p < 0.001). The linear regression analysis indicated that PSP/REG Iα was associated with UA, BUN, and eGFR. High PSP/REG Iα concentrations were closely associated with renal dysfunction in pregnant women. Our study provides clinical evidence that serum PSP/REG Iα levels could be a novel biomarker for assessment of renal function in pregnant women.

Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature

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.

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

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.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

What we know and do not know about women and kidney diseases; Questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically women's kidney health on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state in which acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. Various autoimmune and other conditions are more likely to impact women, with profound consequences for child bearing and the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we know and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

Risk Factors for Adverse Fetal Outcome in Hemodialysis Pregnant Women

Introduction

Pregnancy in women on dialysis is associated with a higher risk of adverse events, and the best care for this population remains to be established.

Methods

In this series, we aimed to identify factors associated with the risk of adverse fetal outcomes among 93 pregnancies in women on hemodialysis. Dialysis dose was initially assigned according to the presence of residual diuresis, body weight, and years on dialysis. Subsequent adjustments on dialysis dose were performed according to several parameters.

Results

The overall successful delivery rate was 89.2%, with a dialysis regimen of 2.6 ± 0.7 h/d, 15.4 ± 4.0 h/wk, and mean weekly standard urea Kt/V of 3.3 ± 0.6. In the logistic models, preeclampsia, lupus, primigravida, and average midweek blood urea nitrogen (BUN) level were positively related to the risk of a composite outcome of perinatal death or extreme prematurity, whereas polyhydramnios was inversely related to it. In multivariable linear regression, preeclampsia, polyhydramnios, primigravida, average midweek BUN, and residual diuresis remained significantly and independently related to fetal weight, which is a surrogate marker of fetal outcome. An average midweek BUN of 35 mg/dl was the best value for discriminating the composite outcome, and BUN ≥35 mg/dl was associated with a significant difference in a Kaplan-Meier curve (P = 0.01).

Conclusion

Our results showed that a good fetal outcome could be reached and that preeclampsia, lupus, primigravida, residual diuresis, polyhydramnios, and hemodialysis dose were important variables associated with this outcome. In addition, we suggested that a midweek BUN <35 mg/dl might be used as a target for adjusting dialysis dose until hard data were generated.

What we do and do not know about women and kidney diseases; Questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day

Chronic kidney disease (CKD) affects approximately 10% of the world’s adult population; it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women’s Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women’s health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world’s population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, which not only offers an opportunity for diagnosis of kidney disease, but also states where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for childbearing, and on the fetus. Women have different complications on dialysis than men and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease and what we might learn in the future to improve outcomes worldwide.

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on World Kidney Day and International Woman's Day

Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly.Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants.In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

What We Do and Do Not Know About Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Woman's Day

BACKGROUND

Chronic kidney disease affects approximately 10% of the world's adult population: It is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus giving an occasion to reflect on open questions on the importance of kidney health in women for the present and the future generations.

OBJECTIVES

In this review, we summarize some aspects that are unique to women's kidney health, offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly.

FINDINGS

Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is not only a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for childbearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants.

CONCLUSION

Improving knowledge on women, kidney health, and kidney disease, may be a way to improve outcomes of kidney diseases worldwide.

What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women's Day

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on World Kidney Day and International Women's Day

Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Woman's Day

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women's Day

Chronic kidney disease affects approximately 10$ of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50$ of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

Investigation of a Rise in Obstetric Acute Renal Failure in the United States, 1999-2011

OBJECTIVE

To estimate whether the reported increase in obstetric acute renal failure in the United States was attributable to a concurrent rise in postpartum hemorrhage, a change in other risk factors, or changes in the diagnosis of acute renal failure.

METHODS

We conducted a retrospective cohort study to quantify temporal trends in acute renal failure among 10,969,263 hospital deliveries in the United States from 1999 to 2011 using data from the Nationwide Inpatient Sample. Dialysis and maternal death were used as markers of severe acute renal failure. Logistic regression was used to determine whether changes in risk factors explained the temporal rise in acute renal failure.

RESULTS

Obstetric acute renal failure rose from 2.4 to 6.3 per 10,000 deliveries between 1999-2001 and 2010-2011, a 10% yearly increase (95% confidence interval [CI] 8-11%) and adjustment for risk factors only partially explained the rise (adjusted yearly increase 6%, 95% CI 5-8%). The overall severity of acute renal failure decreased, although acute renal failure with dialysis rose from 0.27 to 0.36 per 10,000 deliveries (P for trend=.01), and acute renal failure associated with maternal death increased from 0.13 to 0.23 per 10,000 deliveries (P for trend=.01). The temporal increase in acute renal failure with dialysis was abolished by adjustment for chronic kidney disease and chronic hypertension.

CONCLUSION

Changes in diagnosis or ascertainment have led to substantial increases in obstetric acute renal failure, whereas increases in chronic kidney disease and chronic hypertension among pregnant women have resulted in modest but significant increases in acute renal failure with dialysis.

Pregnancy and kidney disease: from medicine based on exceptions to exceptional medicine

The Webster dictionary defines exception as an anomaly, a person or thing that does not follow a rule, while the adjective exceptional has a different nuance, and means "above average". These two words may describe how obstetric nephrology has shifted from the description of very rare cases, to the development of a complex new and fascinating branch of medicine, that counterbalances obstetricians' usually optimistic outlook by focusing on subtle challenges posed by chronic diseases, and mitigate the frequently grim approach of nephrologists, with a message of hope: women with kidney disease can have the same basic life goals as healthy women their age. Although studies relating to kidney disease in pregnancy are being published more frequently, not all questions have been considered or answered, and clinicians are often challenged by a lack of detailed information and practical guidelines. Thus in this complex, difficult, but also fascinating and evolving panorama, the Journal of Nephrology is publishing a issue dedicated to obstetric nephrology, in an attempt to contribute to the development of this field, with the specific aim of offering practical insights and critical contributions capable of helping clinicians in the management of these "exceptional exceptions".

Pregnancy in chronic kidney disease and kidney transplantation

Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.

Effect of dialysis on fetal heart rate: is inpatient admission for fetal monitoring necessary?

OBJECTIVE

Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure.

METHODS

Retrospective cohort study over a 13-year period (2000-2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal-Wallis test was used and statistical significance was set at p < 0.05.

RESULTS

There were no significant differences in late decelerations (p = 0.2) between cases and controls. Significantly fewer variable decelerations (p = 0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p = 0.02) were noted during HD compared to controls.

CONCLUSION

There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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%).

[How to manage a patient with chronic arterial hypertension during pregnancy and the postpartum period]

The management of chronic arterial hypertension during pregnancy and postpartum requires first to estimate the risk of the pregnancy, linked with the severity of hypertension, with cardiac and renal involvement, with its cause as well as with the background (obesity, diabetes, possible history of placental vascular pathology). On a very practical approach, antihypertensive drug has to be started or increased if systolic pressure reaches or exceeds 160 mmHg or if diastolic pressure reaches or exceeds 105 mmHg. Below this level, there are no evidence-based medicine data, but it seems reasonable to treat if pressure increases over 150/100 mmHg (140/90 mmHg in case of ambulatory monitoring). Excessive pressure figures control must be avoided as much as insufficient ones: in practice, it is necessary to decrease the treatment dose if figures are below 130/80 mmHg. Three antihypertensive drugs are consensually recommended today: alphametyldopa, calcium-channel blockers and labetalol. Monotherapy is most often sufficient; if needed, two of these drugs can easily be associated, and even three if necessary. Converting enzyme inhibitors and angiotensin receptor II antagonists should not be prescribed to pregnant women. Betablockers and diuretics are not recommended. Whatever is the antihypertensive drug used, it is necessary to detect the signs of bad placenta blood circulation with uterine Doppler ultrasound and regular controls of fetal growth, and to check for appearance of proteinuria, defining then over-imposed pre-eclampsia needing immediate admission to the maternity. After delivery, lacatation suppresion with bromocriptin should not be prescribed.

Renal disease and hypertension in pregnancy

Because women are becoming pregnant at a later age, hypertension is more commonly encountered in pregnancy. In addition, with increasing numbers of young women living with renal transplants and kidney disease, it is important for physicians to be aware of the effects of pregnancy on these diseases. A multidisciplinary approach is essential to assess and care for pregnant women with kidney disease. Pre-pregnancy counselling should be offered to all women with chronic kidney disease. A review of medication to avoid teratogenicity and optimise the disease prior to conception is the ideal. Pregnancy may be the first medical review for a young woman, who may present with a previously undiagnosed renal problem.

Subclinical thyroid disease and the incidence of hypertension in pregnancy

OBJECTIVE

To estimate the possibility of long-term effects of subclinical thyroid dysfunction on hypertension and other cardiovascular-related conditions during pregnancy.

METHODS

This is a secondary analysis of a prospective prenatal population-based study in which serum thyroid-function analytes were measured from November 2000 through April 2003. Women with evidence of overt thyroid disease were excluded. The remaining women were classified as being euthyroid, having subclinical hyperthyroid, or having subclinical hypothyroid, and the frequency of pregnancy-associated hypertensive disorders was compared between these groups.

RESULTS

Pregnancy outcomes in 24,883 women were analyzed for pregnancy hypertension, classified as gestational hypertension, mild preeclampsia, or severe preeclampsia. The incidence of hypertensive disorders were compared between the three cohorts. The overall incidences of hypertension in pregnancy were 6.2%, 8.5%, and 10.9% in the subclinical hyperthyroid, euthyroid, and subclinical hypothyroid groups, respectively, and were found to be significant when unadjusted (P=.016). After adjusting for confounding factors, there was a significant association between subclinical hypothyroidism and severe preeclampsia (adjusted odds ratio 1.6, 95% confidence interval 1.1-2.4; P=.03).

CONCLUSION

Women with subclinical hypothyroidism identified during pregnancy have an increased risk for severe preeclampsia when compared with euthyroid women.

LEVEL OF EVIDENCE

II.