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Attini R, Cabiddu G, Ciabatti F, Montersino B, Carosso AR, Gernone G, Gammaro L, Moroni G, Torreggiani M, Masturzo B, Santoro D, Revelli A, Piccoli GB. Chronic kidney disease, female infertility, and medically assisted reproduction: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology. J Nephrol 2023; 36:1239-1255. [PMID: 37354277 PMCID: PMC11081994 DOI: 10.1007/s40620-023-01670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/26/2023]
Abstract
Fertility is known to be impaired more frequently in patients with chronic kidney disease than in the general population. A significant proportion of chronic kidney disease patients may therefore need Medically Assisted Reproduction. The paucity of information about medically assisted reproduction for chronic kidney disease patients complicates counselling for both nephrologists and gynaecologists, specifically for patients with advanced chronic kidney disease and those on dialysis or with a transplanted kidney. It is in this context that the Project Group on Kidney and Pregnancy of the Italian Society of Nephrology has drawn up these best practice guidelines, merging a literature review, nephrology expertise and the experience of obstetricians and gynaecologists involved in medically assisted reproduction. Although all medically assisted reproduction techniques can be used for chronic kidney disease patients, caution is warranted. Inducing a twin pregnancy should be avoided; the risk of bleeding, thrombosis and infection should be considered, especially in some categories of patients. In most cases, controlled ovarian stimulation is needed to obtain an adequate number of oocytes for medically assisted reproduction. Women with chronic kidney disease are at high risk of kidney damage in case of severe ovarian hyperstimulation syndrome, and great caution should be exercised so that it is avoided. The higher risks associated with the hypertensive disorders of pregnancy, and the consequent risk of chronic kidney disease progression, should likewise be considered if egg donation is chosen. Oocyte cryopreservation should be considered for patients with autoimmune diseases who need cytotoxic treatment. In summary, medically assisted reproduction is an option for chronic kidney disease patients, but the study group strongly advises extensive personalised counselling with a multidisciplinary healthcare team and close monitoring during the chosen medically assisted reproduction procedure and throughout the subsequent pregnancy.
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Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Gianfranca Cabiddu
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, G. Brotzu, University of Cagliari, Cagliari, Italy
| | - Francesca Ciabatti
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Benedetta Montersino
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Andrea Roberto Carosso
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Giuseppe Gernone
- UOSVD di Nefrologia e Dialisi ASL Bari. P.O. "S. Maria degli Angeli", Putignano, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro San Bonifacio, San Bonifacio, Italy
| | - Gabriella Moroni
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037, Le Mans, France
| | - Bianca Masturzo
- Division of Obstetrics and Gynaecology, Department of Maternal-Neonatal and Infant Health, Ospedale Degli Infermi, University of Turin, Biella, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. "G. Martino", University of Messina, 98125, Messina, Italy
| | - Alberto Revelli
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Giorgina Barbara Piccoli
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037, Le Mans, France.
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Bajaj SS, Jain B, Stanford FC. Weight gain after in vitro fertilization: a potential consequence of controlled ovarian stimulation. J Assist Reprod Genet 2022; 39:973-976. [PMID: 35218460 PMCID: PMC9051006 DOI: 10.1007/s10815-022-02444-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
In the USA, 42% of adult women were estimated to have obesity, and 13% of women of childbearing age similarly have impaired fecundity. Obesity is associated with infertility such that patients with obesity often seek out in vitro fertilization (IVF) services. Here, we report on the case of a woman with childhood-onset class II obesity who had been undergoing treatment with phentermine and topiramate prior to undergoing 3 cycles of IVF. With each cycle, the patient temporarily gained 13-15 lbs. during controlled ovarian stimulation (COS). Weight gain from COS may be clinically relevant and merits further study to optimize weight status across women's reproductive life and to better assist women who gain weight secondary to IVF. Incorporating weight monitoring into IVF protocols may also help better characterize the scope of weight gain from COS.
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Affiliation(s)
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Fatima Cody Stanford
- MGH Weight Center, Department of Medicine-Division of Endocrinology-Neuroendocrine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA, 02114, USA.
- Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), 4th Floor, Weight Center, 50 Staniford Street, Boston, MA, 02114, USA.
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Rodríguez-Benitez P, Aracil Moreno I, Oliver Barrecheguren C, Cuñarro López Y, Yllana F, Pintado Recarte P, Arribas CB, Álvarez-Mon M, Ortega MA, De Leon-Luis JA. Maternal-Perinatal Variables in Patients with Severe Preeclampsia Who Develop Acute Kidney Injury. J Clin Med 2021; 10:jcm10235629. [PMID: 34884331 PMCID: PMC8658116 DOI: 10.3390/jcm10235629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction: At present, we are witnessing an increase in preeclampsia, especially the most severe forms, which are associated with an increased risk of maternal-perinatal morbidity and mortality. As a severity criterion, acute kidney injury (AKI) has been associated with a worse prognosis, and for this reason, the maternal and perinatal variables associated with AKI in patients with severe preeclampsia (SP) were analysed in this study. Methods: An observational, retrospective, single-centre study of patients with SP treated at a tertiary hospital between January 2007 and December 2018 was conducted. The case criteria based on the criteria established by the ACOG Practice Guidelines for Gestational Hypertension and Preeclampsia. AKI is considered when serum creatinine exceeds 1.1 mg/dL in a pregnant woman with previously normal renal function. In patients with existing chronic kidney disease (CKD), it is referred to as AKI if the baseline serum creatinine increases by 1.5 fold. Pregestational, gestational and postpartum variables were analysed up to 12 weeks postpartum using univariate and multivariate logistic regression analysis. Results: During the study period, 76,828 births were attended, and 303 pregnant women were diagnosed with SP. The annual incidence of SP increased gradually throughout the study period, reaching 1.79/100 births/year in 2018. Acute kidney injury (AKI) occurred in 24.8% of the patients. The multivariate analysis revealed an increased association with a history of previous CKD, the use of assisted reproductive techniques and caesarean section. Uric acid and thrombotic microangiopathy (TMA) had a high correlation with AKI. Indications for caesarean section are associated with AKI in SP. Regarding perinatal outcomes in cases of AKI, there was a higher percentage of neonates who required foetal lung maturation with steroids and an increased need for NICU admission. No case of maternal death was recorded; however, an increase in neonatal mortality was found among patients who did not develop AKI. After 12 weeks postpartum, 72 patients were referred to the nephrology consultation for persistent hypertension, proteinuria or renal failure. Conclusions: In preeclampsia, AKI is a common complication, especially among patients with a history of CKD, those who became pregnant using assisted reproduction techniques and those who delivered via caesarean section. The perinatal impact of AKI is mainly centred on a higher rate of NICU admission and a lower mortality rate. Among biochemical and haematological markers, the uric acid level prior to renal failure has a direct and significant correlation with the risk of AKI, as does the development of TMA in patients with preeclampsia. Therefore, the monitoring of renal function in cases of preeclampsia should be strict, and referral for a nephrology consultation may be necessary in some cases.
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Affiliation(s)
- Patrocinio Rodríguez-Benitez
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Nephrology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Irene Aracil Moreno
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Cristina Oliver Barrecheguren
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Yolanda Cuñarro López
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Fátima Yllana
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Pilar Pintado Recarte
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Coral Bravo Arribas
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, University of Alcala, 28801 Alcala de Henares, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases-Rheumatology, Oncology Service an Internal Medicine, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcala de Henares, Spain
| | - Miguel A. Ortega
- Department of Medicine and Medical Specialities, University of Alcala, 28801 Alcala de Henares, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Correspondence:
| | - Juan A. De Leon-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (I.A.M.); (C.O.B.); (Y.C.L.); (F.Y.); (P.P.R.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
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Oliverio AL, Bramham K, Hladunewich MA. Pregnancy and CKD: Advances in Care and the Legacy of Dr Susan Hou. Am J Kidney Dis 2021; 78:865-875. [PMID: 34656369 DOI: 10.1053/j.ajkd.2021.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/13/2021] [Indexed: 11/11/2022]
Abstract
Dr Susan Hou began her illustrious nephrology career at a time when pregnancy in women with chronic kidney disease (CKD) was hazardous and actively discouraged. Her pioneering research in women's health provided much of the early outcome data that shaped our current understanding of CKD and pregnancy. Although many uncertainties regarding optimal management of this vulnerable patient group remain, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists have been inspired by Dr Hou's lifetime of work and are grateful for her generous collaborations. In this In Practice Review, we honor her legacy by providing an update of current literature and clinical management guidance in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a pregnancy.
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Affiliation(s)
- Andrea L Oliverio
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, United Kingdom; Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michelle A Hladunewich
- Divisions of Nephrology and Obstetrics, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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Li F, Chen Y, Niu A, He Y, Yan Y. Nomogram Model to Predict the Probability of Ovarian Hyperstimulation Syndrome in the Treatment of Patients With Polycystic Ovary Syndrome. Front Endocrinol (Lausanne) 2021; 12:619059. [PMID: 34421814 PMCID: PMC8377671 DOI: 10.3389/fendo.2021.619059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 07/07/2021] [Indexed: 11/21/2022] Open
Abstract
Objective The objective of this study was to explore the risk factors of ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) and to establish a nomogram model evaluate the probability of OHSS in PCOS patients. Methods We retrospectively analyzed clinical data from 4,351 patients with PCOS receiving IVF/ICSI in our reproductive medical center. The clinical cases were randomly divided into a modeling group (3,231 cases) and a verification group (1,120 cases) according to a ratio of about 3:1. The independent risk factors correlation with the occurrence of OHSS was identified by logistic regression analysis. Based on the selected independent risk factors and correlated regression coefficients, we established a nomogram model to predict the probability of OHSS in PCOS patients, and the predictive accuracy of the model was measured using the area under the receiver operating curve (AUC). Results Univariate and multivariate logistic regression analyses showed that FSH (OR, 0.901; 95% CI, 0.847-0.958; P<0.001), AMH (OR, 1.259; 95% CI, 1.206-1.315; P<0.001), E2 value on the day of hCG injection (OR, 1.122; 95% CI, 1.021-1.253; P<0.001), total dosage of Gn used (OR, 1.010; 95% CI, 1.002-1.016; P=0.041), and follicle number on the day of hCG injection (OR, 0.134; 95% CI, 1.020-1.261; P=0.020) are the independent risk factors for OHSS in PCOS patients. The AUC of the modeling group is 0.827 (95% CI, 0.795-0.859), and the AUC of the verification group is 0.757 (95% CI, 0.733-0.782). Conclusion The newly established nomogram model has proven to be a novel tool that can effectively, easily, and intuitively predict the probability of OHSS in the patients with PCOS, by which the clinician can set up a better clinical management strategies for conducting a precise personal therapy.
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Affiliation(s)
- Fei Li
- Center for Reproductive Medicine, The First People’s Hospital of Shangqiu, Henan, China
- Center for Reproductive Medicine, The First Affiliated Hospital of Zheng Zhou University, Henan, China
| | - Ying Chen
- Center for Reproductive Medicine, The First People’s Hospital of Shangqiu, Henan, China
| | - Aiqin Niu
- Center for Reproductive Medicine, The First People’s Hospital of Shangqiu, Henan, China
| | - Yajing He
- Department of Pathology, The First People’s Hospital of Shangqiu, Henan, China
| | - Ying Yan
- Department of Molecular Biology, The First People’s Hospital of Shangqiu, Henan, China
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Vinturache A, Popoola J, Watt-Coote I. The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. J Clin Med 2019; 8:jcm8091396. [PMID: 31500091 PMCID: PMC6780924 DOI: 10.3390/jcm8091396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (PR-AKI) is a heterogeneous disorder with multiple aetiologies that can occur at any time throughout pregnancy and the post-partum period. PR-AKI is an important obstetric complication that is associated with significant maternal and foetal morbidity and mortality. Although there has been an overall decline in the incidence of PR-AKI worldwide, a recent shift in the occurrence of this disease has been reported. Following improvements in obstetric care, PR-AKI incidence has been reduced in developing countries, whereas an increase in PR-AKI incidence has been reported in developed countries. Awareness of the physiological adaptations of the renal system is essential for the diagnosis and management of kidney impairment in pregnancy. In this review we scrutinize the factors that have contributed to the changing epidemiology of PR-AKI and discuss challenges in the diagnosis and management of acute kidney injury (AKI) in pregnancy from an obstetrics perspective. Thereafter we provide brief discussions on the diagnostic approach of certain PR-AKI aetiologies and summarize key therapeutic measures.
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Affiliation(s)
- Angela Vinturache
- Department of Obstetrics & Gynaecology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK.
| | - Joyce Popoola
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
- Department of Nephrology and Transplantation, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
| | - Ingrid Watt-Coote
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
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