1
|
de Jong MF, Nemeth E, Rawee P, Bramham K, Eisenga MF. Anemia in Pregnancy With CKD. Kidney Int Rep 2024; 9:1183-1197. [PMID: 38707831 PMCID: PMC11069017 DOI: 10.1016/j.ekir.2024.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 12/05/2023] [Accepted: 01/08/2024] [Indexed: 05/07/2024] Open
Abstract
Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.
Collapse
Affiliation(s)
- Margriet F.C. de Jong
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
| | - Elizabeta Nemeth
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Pien Rawee
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
| | - Kate Bramham
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Michele F. Eisenga
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
| |
Collapse
|
2
|
Sangkhae V, Fisher AL, Ganz T, Nemeth E. Iron Homeostasis During Pregnancy: Maternal, Placental, and Fetal Regulatory Mechanisms. Annu Rev Nutr 2023; 43:279-300. [PMID: 37253681 PMCID: PMC10723031 DOI: 10.1146/annurev-nutr-061021-030404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Pregnancy entails a large negative balance of iron, an essential micronutrient. During pregnancy, iron requirements increase substantially to support both maternal red blood cell expansion and the development of the placenta and fetus. As insufficient iron has long been linked to adverse pregnancy outcomes, universal iron supplementation is common practice before and during pregnancy. However, in high-resource countries with iron fortification of staple foods and increased red meat consumption, the effects of too much iron supplementation during pregnancy have become a concern because iron excess has also been linked to adverse pregnancy outcomes. In this review, we address physiologic iron homeostasis of the mother, placenta, and fetus and discuss perturbations in iron homeostasis that result in pathological pregnancy. As many mechanistic regulatory systems have been deduced from animal models, we also discuss the principles learned from these models and how these may apply to human pregnancy.
Collapse
Affiliation(s)
- Veena Sangkhae
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA;
| | - Allison L Fisher
- Endocrine Unit and Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas Ganz
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA;
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA;
| |
Collapse
|
3
|
Ssewanyana D, Borque SL, Lye SJ, Matthews SG. Hepcidin across pregnancy and its correlation with maternal markers of iron and inflammation, maternal body weight outcomes, and offspring neurodevelopmental outcomes: a systematic review and meta-analysis. AJOG GLOBAL REPORTS 2023; 3:100222. [PMID: 37645642 PMCID: PMC10461250 DOI: 10.1016/j.xagr.2023.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE This study evaluated the correlation between maternal hepcidin and other biomarkers of iron status, markers of inflammation, and maternal body weight during pregnancy, as well as neurodevelopment in the offspring. DATA SOURCES PubMed, Web of Science, Scopus, and Embase were searched from inception until March 2022. STUDY ELIGIBILITY CRITERIA Studies conducted among pregnant women without apparent pregnancy complications were included. Eligible studies reported correlation coefficients between maternal hepcidin and any outcomes of maternal biomarkers of iron status or inflammatory load during pregnancy, prenatal maternal body weight, and offspring neurodevelopment. Studies without correlation data were eligible if they quantitatively reported volumes of both maternal hepcidin and any marker of iron status and/or inflammatory load during gestation. METHODS Pooled correlation coefficients between maternal hepcidin and outcomes of interest were calculated using the Fisher r-to-Z transformation. Both fixed-effects and DerSimonian and Laird random-effects models were used to calculate pooled correlation coefficient. When meta-analysis was not feasible, results were descriptively synthesized. RESULTS Forty-six studies with 6624 participants were eligible. Hepcidin was significantly correlated with hemoglobin in the third trimester (r=0.21; 95% confidence interval, 0.1-0.32); ferritin in the first (r=0.31; 95% confidence interval, 0.01-0.61) and third trimester (r=0.35; 95% confidence interval, 0.23-0.48); soluble transferrin receptor in the second trimester (r=-0.27; 95% confidence interval, -0.4 to -0.14); total iron-binding capacity in the second trimester (r=0.37; 95% confidence interval, 0.24-0.50); and serum iron in the third trimester (r=0.11; 95% confidence interval, 0.02-0.19). Hepcidin was significantly correlated with the inflammatory marker interleukin-6 in the third trimester (r=0.26; 95% confidence interval, 0.17-0.34) and C-reactive protein in the second (r=0.16; 95% confidence interval, 0.03-0.30) and third trimester (r=0.28; 95% confidence interval, 0.04-0.52). Four out of 5 studies reported weak-to-moderate positive correlation between hepcidin and body mass index. Hepcidin levels varied across body mass index categories. No single study reported the relationship between maternal hepcidin and neurodevelopment in offspring. CONCLUSION Hepcidin weakly to moderately correlates with biomarkers of iron and inflammation in pregnancy.
Collapse
Affiliation(s)
- Derrick Ssewanyana
- Departments of Physiology (Drs Ssewanyana, Lye, and Matthews)
- Medicine (Drs Ssewanyana, Lye, and Matthews), University of Toronto, Toronto, Canada
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, Canada (Drs Ssewanyana, Lye, and Matthews)
| | - Stephane L. Borque
- Department of Anesthesiology and Pain Medicine and Pharmacology, University of Alberta, Edmonton, Canada (Dr Borque)
| | - Stephen J. Lye
- Departments of Physiology (Drs Ssewanyana, Lye, and Matthews)
- Medicine (Drs Ssewanyana, Lye, and Matthews), University of Toronto, Toronto, Canada
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, Canada (Drs Ssewanyana, Lye, and Matthews)
| | - Stephen G. Matthews
- Departments of Physiology (Drs Ssewanyana, Lye, and Matthews)
- Medicine (Drs Ssewanyana, Lye, and Matthews), University of Toronto, Toronto, Canada
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, Canada (Drs Ssewanyana, Lye, and Matthews)
| |
Collapse
|
4
|
Abstract
Hepcidin, the iron-regulatory hormone, determines plasma iron concentrations and total body iron content. Hepcidin, secreted by hepatocytes, functions by controlling the activity of the cellular iron exporter ferroportin, which delivers iron to plasma from intestinal iron absorption and from iron stores. Hepcidin concentration in plasma is increased by iron loading and inflammation and is suppressed by erythropoietic stimulation and during pregnancy. Hepcidin deficiency causes iron overload in hemochromatosis and anemias with ineffective erythropoiesis. Hepcidin excess causes iron-restrictive anemias including anemia of inflammation. The development of hepcidin diagnostics and therapeutic agonists and antagonists should improve the treatment of iron disorders.
Collapse
Affiliation(s)
- Elizabeta Nemeth
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA;
| | - Tomas Ganz
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA;
| |
Collapse
|
5
|
Whelan R, Schaeffer L, Olson I, Folger LV, Alam S, Ajaz N, Ladhani K, Rosner B, Wylie BJ, Lee ACC. Measurement of symphysis fundal height for gestational age estimation in low-to-middle-income countries: A systematic review and meta-analysis. PLoS One 2022; 17:e0272718. [PMID: 36007078 PMCID: PMC9409500 DOI: 10.1371/journal.pone.0272718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 07/25/2022] [Indexed: 11/19/2022] Open
Abstract
In low- and middle-income countries (LMIC), measurement of symphysis fundal height (SFH) is often the only available method of estimating gestational age (GA) in pregnancy. This systematic review aims to summarize methods of SFH measurement and assess the accuracy of SFH for the purpose of GA estimation. We searched PubMed, EMBASE, Cochrane, Web of Science, POPLINE, and WHO Global Health Libraries from January 1980 through November 2021. For SFH accuracy, we pooled the variance of the mean difference between GA confirmed by ultrasound versus SFH. Of 1,003 studies identified, 37 studies were included. Nineteen different SFH measurement techniques and 13 SFH-to-GA conversion methods were identified. In pooled analysis of five studies (n = 5838 pregnancies), 71% (95% CI: 66-77%) of pregnancies dated by SFH were within ±14 days of ultrasound confirmed dating. Using the 1 cm SFH = 1wk assumption, SFH underestimated GA compared with ultrasound-confirmed GA (mean bias: -14.0 days) with poor accuracy (95% limits of agreement [LOA]: ±42.8 days; n = 3 studies, 2447 pregnancies). Statistical modeling of three serial SFH measurements performed better, but accuracy was still poor (95% LOA ±33 days; n = 4 studies, 4391 pregnancies). In conclusion, there is wide variation in SFH measurement and SFH-to-GA conversion techniques. SFH is inaccurate for estimating GA and should not be used for GA dating. Increasing access to quality ultrasonography early in pregnancy should be prioritized to improve gestational age assessment in LMIC.
Collapse
Affiliation(s)
- Rachel Whelan
- Global Advancement of Infants and Mothers (AIM) Lab, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Lauren Schaeffer
- Global Advancement of Infants and Mothers (AIM) Lab, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Ingrid Olson
- Global Advancement of Infants and Mothers (AIM) Lab, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Lian V. Folger
- Global Advancement of Infants and Mothers (AIM) Lab, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Maternal and Child Health, University of North Carolina Chapel, Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Saima Alam
- Berkshire Medical Center, Pittsfield, MA, United States of America
| | - Nayab Ajaz
- Tufts University School of Medicine, Boston, MA, United States of America
| | - Karima Ladhani
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Bernard Rosner
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Blair J. Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Anne C. C. Lee
- Global Advancement of Infants and Mothers (AIM) Lab, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| |
Collapse
|
6
|
González-Fernández D, Nemeth E, Pons EDC, Sinisterra OT, Rueda D, Starr L, Sangkhae V, Murillo E, Scott ME, Koski KG. Multiple Indicators of Undernutrition, Infection, and Inflammation in Lactating Women Are Associated with Maternal Iron Status and Infant Anthropometry in Panama: The MINDI Cohort. Nutrients 2022; 14:nu14173497. [PMID: 36079755 PMCID: PMC9460351 DOI: 10.3390/nu14173497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 02/06/2023] Open
Abstract
Maternal infections, nutrient deficiencies, and inflammation (MINDI) co-exist in lactating indigenous women in Panama, but their impact on maternal iron status and infant growth is unknown. For this secondary analysis of cross-sectional data of lactating mothers from our MINDI cohort, we investigated associations of MINDI variables with maternal anemia, elevated serum transferrin receptor (sTfR), low serum iron, hepcidin, ferritin, and infant weight-for-age (WAZ), length-for-age (LAZ), and head-circumference-for-age (HCAZ) Z-scores in 99 mother-infant dyads. A bootstrapping resampling procedure preselected covariates for inclusion in multivariable regressions models from chronic maternal infections and nutritional status [folate, vitamins A, D, retinol-binding protein (RBP), insulin-growth factor-1 (IGF-1)] and inflammation [C-reactive protein (CRP), cytokines, platelet indices] indicators. Anemia was prevalent (53.5%) but underestimated due to widespread low plasma volume (<2.2 L, 79.9%) and was associated with indicators of malnutrition [lower IGF-1, body mass index (BMI), vitamin D, and intake of green/leafy vegetables], but not inflammation. Higher CRP was associated with lower serum iron, and higher hepcidin and ferritin, whereas maternal platelets were associated with lower HCAZ (β = −0.22), WAZ (β = −0.17), and LAZ (β = −0.17). Higher LAZ was also associated with maternal serum vitamin D (β = 0.23), whereas maternal iron supplementation lowered LAZ (β = −0.22). Assessment of iron status in this MINDI cohort is complex and supplementation strategies must consider consequences for both the mother and the infant.
Collapse
Affiliation(s)
- Doris González-Fernández
- School of Human Nutrition, McGill University, (Macdonald Campus), Ste-Anne de Bellevue, QC H9X 3V9, Canada
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA 90089, USA
| | | | | | - Delfina Rueda
- “Comarca Ngäbe-Buglé” Health Region, Panamanian Ministry of Health, Panama City, Panama
| | - Lisa Starr
- Department of Biochemistry, University of Panama, Panama City, Panama
| | - Veena Sangkhae
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA 90089, USA
| | - Enrique Murillo
- Department of Biochemistry, University of Panama, Panama City, Panama
| | - Marilyn E. Scott
- Institute of Parasitology, McGill University, (Macdonald Campus), Ste-Anne de Bellevue, QC H9X 3V9, Canada
| | - Kristine G. Koski
- School of Human Nutrition, McGill University, (Macdonald Campus), Ste-Anne de Bellevue, QC H9X 3V9, Canada
- Correspondence: ; Tel.: +1-514-398-7845
| |
Collapse
|