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Jaques DA, Dufey Teso A, Wuerzner G, Martinez De Tejada B, Santagata M, Othenin Girard V, Le Tinier B, Pechere Bertschi A, Ponte B. Association of serum copeptin and urinary uromodulin with kidney function, blood pressure and albuminuria at 6 weeks post-partum in pre-eclampsia. Front Cardiovasc Med 2024; 11:1310300. [PMID: 38500759 PMCID: PMC10945001 DOI: 10.3389/fcvm.2024.1310300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/14/2024] [Indexed: 03/20/2024] Open
Abstract
Background Preeclampsia (PE) is associated with subsequent higher risk of cardiovascular and kidney disease. Serum copeptin, as a proxy for vasopressin, and urinary uromodulin, were associated with PE physiopathology and kidney functional mass respectively. We describe concentrations of these proteins in the post-partum period and characterize their association with persistent hypertension (HTN) or albuminuria. Methods Patients with PE and healthy controls with uncomplicated pregnancy were prospectively included at two teaching hospitals in Switzerland. Clinical parameters along with serum copeptin and urinary uromodulin were measured at 6 weeks post-partum. PE patients were further characterized based on presence of HTN (defined as either systolic BP (SBP) ≥140 mmHg or diastolic (BP) ≥90 mmHg) or albuminuria [defined as urinary albumin to creatinine ratio (ACR) ≥3 mg/mmol]. Results We included 226 patients with 35 controls, 120 (62.8%) PE with persistent HTN/albuminuria and 71 (37.1%) PE without persistent HTN/albuminuria. Median serum copeptin concentration was 4.27 (2.9-6.2) pmol/L without differences between study groups (p > 0.05). Higher copeptin levels were associated with higher SBP in controls (p = 0.039), but not in PE (p > 0.05). Median urinary uromodulin concentration was 17.5 (7.8-28.7) mg/g with lower levels in PE patients as compared to healthy controls (p < 0.001), but comparable levels between PE patients with or without HTN/albuminuria (p > 0.05). Higher uromodulin levels were associated with lower albuminuria in PE as well as control patients (p = 0.040). Conclusion Serum copeptin levels at 6 weeks post-partum are similar between PE patients and healthy controls and cannot distinguish between PE with or without residual kidney damage. This would argue against a significant pathophysiological role of the vasopressin pathway in mediating organ damage in the post-partum period. On the opposite, post-partum urinary uromodulin levels are markedly lower in PE patients as compared to healthy controls, potentially reflecting an increased susceptibility to vascular and kidney damage that could associate with adverse long-term cardiovascular and kidney outcomes.
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Affiliation(s)
- David A. Jaques
- Service of Nephrology and Hypertension, Geneva University Hospitals, Geneva, Switzerland
| | - Anne Dufey Teso
- Service of Nephrology and Hypertension, Geneva University Hospitals, Geneva, Switzerland
| | - Grégoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Begona Martinez De Tejada
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marika Santagata
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Véronique Othenin Girard
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Bénédicte Le Tinier
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | | | - Belen Ponte
- Service of Nephrology and Hypertension, Geneva University Hospitals, Geneva, Switzerland
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Artan AS, Fleetwood V, Guller N, Oto OA, Mirioglu S, Yazici H, Turkmen A, Caliskan Y, Lentine KL. Pregnancy in Living Kidney Donors: An Evidence-Based Review. CURRENT TRANSPLANTATION REPORTS 2023; 10:110-116. [PMID: 37743976 PMCID: PMC10512453 DOI: 10.1007/s40472-023-00402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 09/26/2023]
Abstract
Purpose of review To review the current studies and guidelines on the risk of adverse pregnancy outcomes in female kidney donors. Recent findings Living kidney donors include a significant amount of young women of child-bearing age. Safety and possible risks of pregnancy after donation are a concern for female kidney donor candidates. Many current studies indicate a higher risk of preeclampsia in women after kidney donation. Considering the increasing number of living kidney donors, the maternal outcomes of living kidney donation is an active area of research. Summary Guidelines and consensus statements on the risk of pregnancy in living kidney donors recommend close monitoring of blood pressure, weight gain, and proteinuria during pregnancy. Current studies indicate an increased risk of hypertensive disorders of pregnancy in living kidney donors. Counseling and informing donor candidates about the possible risks is important.
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Affiliation(s)
- Ayse Serra Artan
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Vidyaratna Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Nurane Guller
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Safak Mirioglu
- Division of Nephrology, Department of Internal Medicine, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yasar Caliskan
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
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Al Sayyab M, Chapman A. Pregnancy in Autosomal Dominant Polycystic Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:454-460. [PMID: 38032583 DOI: 10.1053/j.akdh.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder occurring in approximately 1:1000 individuals. ADPKD is characterized by gradual cyst expansion and kidney enlargement and is a slowly progressive disorder where patients typically initiate renal replacement therapy in the sixth decade of life. The vast majority of women with ADPKD become pregnant in the third or fourth decade, often before knowing that they have ADPKD, in the setting of normal kidney function or chronic kidney disease Stage 1. In ADPKD, pregnancy outcomes for mother and baby differ from the general population, and long-term consequences of maternal complications from pregnancy are common in ADPKD. In the current era of genetic testing, options to consider pre-implantation genetic screening are becoming more available. This chapter will review renal physiologic and anatomic changes that occur in pregnancy, the potential impact of ADPKD on maternal and fetal outcomes, medical management during pregnancy, the impact of pregnancy on long-term outcomes in women with ADPKD, and options for families with ADPKD planning to undergo pregnancy with regard to genetic testing.
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Affiliation(s)
- Mina Al Sayyab
- Department of Medicine, University of Chicago, Chicago, IL
| | - Arlene Chapman
- Department of Medicine, University of Chicago, Chicago, IL.
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Moroni G, Calatroni M, Donato B, Ponticelli C. Kidney Biopsy in Pregnant Women with Glomerular Diseases: Focus on Lupus Nephritis. J Clin Med 2023; 12:jcm12051834. [PMID: 36902621 PMCID: PMC10003332 DOI: 10.3390/jcm12051834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Despite significant improvements of renal and obstetrical management, pregnancies in women with glomerular diseases and with lupus nephritis continue to be associated with increased complications both for the mother and the fetus as compared to those of pregnancies in healthy women. To reduce the risk of these complications, planning pregnancy in a phase of stable remission of the underlining disease is necessary. A kidney biopsy is an important event in any phase of pregnancy. A kidney biopsy can be of help during counselling before pregnancy in cases of incomplete remission of the renal manifestations. In these situations, histological data may differentiate active lesions that require the reinforcement of therapy from chronic irreversible lesions that may increase the risk of complications. In pregnant women, a kidney biopsy can identify new-onset systemic lupus erythematous (SLE) and necrotizing or primitive glomerular diseases and distinguish them from other, more common complications. Increasing proteinuria, hypertension, and the deterioration of kidney function during pregnancy may be either due to a reactivation of the underlying disease or to pre-eclampsia. The results of the kidney biopsy suggest the need to initiate an appropriate treatment, allowing the progression of the pregnancy and the fetal viability or the anticipation of delivery. Data from the literature suggest avoiding a kidney biopsy beyond 28 weeks of gestation to minimize the risks associated with the procedure vs. the risk of preterm delivery. In case of the persistence of renal manifestations after delivery in women with a diagnosis of pre-eclampsia, a renal kidney assessment allows the final diagnosis and guides the therapy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-345-872-1910
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Beatriz Donato
- Nephrology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
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Job KM, Dallmann A, Parry S, Saade G, Haas DM, Hughes B, Berens P, Chen JY, Fu C, Humphrey K, Hornik C, Balevic S, Zimmerman K, Watt K. Development of a Generic Physiologically-Based Pharmacokinetic Model for Lactation and Prediction of Maternal and Infant Exposure to Ondansetron via Breast Milk. Clin Pharmacol Ther 2022; 111:1111-1120. [PMID: 35076931 PMCID: PMC10267851 DOI: 10.1002/cpt.2530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 11/11/2022]
Abstract
Ondansetron is commonly used in breastfeeding mothers to treat nausea and vomiting. There is limited information in humans regarding safety of ondansetron exposure to nursing infants and no adequate study looking at ondansetron pharmacokinetics during lactation. We developed a generic physiologically-based pharmacokinetic lactation model for small molecule drugs and applied this model to predict ondansetron transfer into breast milk and characterize infant exposure. Drug-specific model inputs were parameterized using data from the literature. Population-specific inputs were derived from a previously conducted systematic literature review of anatomic and physiologic changes in postpartum women. Model predictions were evaluated using ondansetron plasma and breast milk concentration data collected prospectively from 78 women in the Commonly Used Drugs During Lactation and infant Exposure (CUDDLE) study. The final model predicted breast milk and plasma exposures following a single 4 mg dose of intravenous ondansetron in 1,000 simulated women who were 2 days postpartum. Model predictions showed good agreement with observed data. Breast milk median prediction error (MPE) was 18.4% and median absolute prediction error (MAPE) was 53.0%. Plasma MPE was 32.5% and MAPE was 43.2%. The model-predicted daily and relative infant doses were 0.005 mg/kg/day and 3.0%, respectively. This model adequately predicted ondansetron passage into breast milk. The calculated low relative infant dose indicates that mothers receiving ondansetron can safely breastfeed. The model building blocks and population database are open-source and can be adapted to other drugs.
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Affiliation(s)
- Kathleen M. Job
- Division of Clinical Pharmacology, Department of Pediatrics, The University of Utah, Salt Lake City, Utah, USA
| | - André Dallmann
- Pharmacometrics/Modeling & Simulation, Research & Development, Bayer AG, Leverkusen, Germany
| | - Samuel Parry
- Division of Maternal-Fetal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Saade
- University of Texas Medical Branch–Galveston, Galveston, Texas, USA
| | - David M. Haas
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brenna Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Pamela Berens
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Jia-Yu Chen
- The Emmes Company, LLC, Rockville, Maryland, USA
| | - Christina Fu
- The Emmes Company, LLC, Rockville, Maryland, USA
| | | | - Christoph Hornik
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Kanecia Zimmerman
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, The University of Utah, Salt Lake City, Utah, USA
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Abstract
Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.
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Integration of physiological changes during the postpartum period into a PBPK framework and prediction of amoxicillin disposition before and shortly after delivery. J Pharmacokinet Pharmacodyn 2020; 47:341-359. [DOI: 10.1007/s10928-020-09706-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
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Dallmann A, Ince I, Meyer M, Willmann S, Eissing T, Hempel G. Gestation-Specific Changes in the Anatomy and Physiology of Healthy Pregnant Women: An Extended Repository of Model Parameters for Physiologically Based Pharmacokinetic Modeling in Pregnancy. Clin Pharmacokinet 2018; 56:1303-1330. [PMID: 28401479 DOI: 10.1007/s40262-017-0539-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the past years, several repositories for anatomical and physiological parameters required for physiologically based pharmacokinetic modeling in pregnant women have been published. While providing a good basis, some important aspects can be further detailed. For example, they did not account for the variability associated with parameters or were lacking key parameters necessary for developing more detailed mechanistic pregnancy physiologically based pharmacokinetic models, such as the composition of pregnancy-specific tissues. OBJECTIVES The aim of this meta-analysis was to provide an updated and extended database of anatomical and physiological parameters in healthy pregnant women that also accounts for changes in the variability of a parameter throughout gestation and for the composition of pregnancy-specific tissues. METHODS A systematic literature search was carried out to collect study data on pregnancy-related changes of anatomical and physiological parameters. For each parameter, a set of mathematical functions was fitted to the data and to the standard deviation observed among the data. The best performing functions were selected based on numerical and visual diagnostics as well as based on physiological plausibility. RESULTS The literature search yielded 473 studies, 302 of which met the criteria to be further analyzed and compiled in a database. In total, the database encompassed 7729 data. Although the availability of quantitative data for some parameters remained limited, mathematical functions could be generated for many important parameters. Gaps were filled based on qualitative knowledge and based on physiologically plausible assumptions. CONCLUSION The presented results facilitate the integration of pregnancy-dependent changes in anatomy and physiology into mechanistic population physiologically based pharmacokinetic models. Such models can ultimately provide a valuable tool to investigate the pharmacokinetics during pregnancy in silico and support informed decision making regarding optimal dosing regimens in this vulnerable special population.
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Affiliation(s)
- André Dallmann
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelm-University Münster, Münster, Germany
| | - Ibrahim Ince
- ET-TD-ET Systems Pharmacology CV, Bayer AG, Leverkusen, Germany.
| | - Michaela Meyer
- DD-CS Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Stefan Willmann
- DD-CS Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Thomas Eissing
- ET-TD-ET Systems Pharmacology CV, Bayer AG, Leverkusen, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelm-University Münster, Münster, Germany
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Abstract
Women with chronic kidney disease (CKD) are at risk for adverse pregnancy-associated outcomes, including progression of their underlying renal dysfunction, a flare of their kidney disease, and adverse pregnancy complications such as preeclampsia and preterm delivery. Earlier-stage CKD, as a rule, is a safer time to have a pregnancy, but even women with end-stage kidney disease have attempted pregnancy in recent years. As such, nephrologists need to be comfortable with pregnancy preparation and management at all stages of CKD. In this article, we review the renal physiologic response to pregnancy and the literature with respect to both expected maternal and fetal outcomes among young women at various stages of CKD, including those who attempt to conceive while on dialysis. The general management of young women with CKD and associated complications, including hypertension and proteinuria are discussed. Finally, the emotional impact these pregnancies may have on young women with a chronic disease and the potential benefits of care in a multidisciplinary environment are highlighted.
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Villie P, Dommergues M, Brocheriou I, Piccoli GB, Tourret J, Hertig A. Why kidneys fail post-partum: a tubulocentric viewpoint. J Nephrol 2018; 31:645-651. [PMID: 29637465 DOI: 10.1007/s40620-018-0488-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 03/30/2018] [Indexed: 12/20/2022]
Abstract
Kidneys may fail post-partum in a number of circumstances due, for example, to post-partum haemorrhage, preeclampsia, amniotic fluid embolism or septic abortion. All these conditions in pregnancy and post partum represent a threat not only to the endothelium but also to the renal tubular epithelium, and as such may lead to rapid and also irreversible impairment of the renal function. This paper is a non-systematic review of the literature and of our experience, in which we discuss the main open issues on kidney disease in pregnancy and following delivery, in particular as regards tubular damage, with the aim to help reasoning on acute kidney injury (AKI) following delivery. The review will emphasize the often under-estimated importance of the tubular epithelium in the peri-partum period and will: (1) describe the main characteristics of the renal tissues around delivery; (2) define pregnancy-related AKI according to recent Kidney Disease/Improving Global Outcome (KDIGO) guidelines; (3) discuss the most common circumstances of post-partum AKI; and (4) describe the input expected from urinalysis, renal imaging and kidney biopsy.
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Affiliation(s)
- Patricia Villie
- APHP, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, 4 rue de la Chine, 75020, Paris, France
| | - Marc Dommergues
- Department of Gynecology and Obstetrics, APHP, Groupe Hospitalier La Pitié Salpêtrière Charles Foix, Paris, France
| | - Isabelle Brocheriou
- Department of Pathology, APHP, Hôpital Tenon, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMR_S 1155, 75005, Paris, France
| | - Giorgina Barbara Piccoli
- Centre Hospitalier du Mans Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Jérôme Tourret
- Sorbonne Universités, UPMC Université Paris 06, UMR_S 1155, 75005, Paris, France
| | - Alexandre Hertig
- APHP, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, 4 rue de la Chine, 75020, Paris, France. .,Sorbonne Universités, UPMC Université Paris 06, UMR_S 1155, 75005, Paris, France.
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11
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado; and
- Department of Medicine, Division of Nephrology and
- Department of Physiology, University of Toronto, Ontario, Canada
| | - David Z.I. Cherney
- Department of Medicine, Division of Nephrology and
- Department of Physiology, University of Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Renal dysfunction during pregnancy is a common and serious complication. Understanding normal physiology during pregnancy provides a context to further describe changes in pregnancy that lead to renal dysfunction and may provide clues to better management. RECENT FINDINGS Hormonal changes during pregnancy allow for increased blood flow to the kidneys and altered autoregulation such that glomerular filtration rate (GFR) increases significantly through reductions in net glomerular oncotic pressure and increased renal size. The mechanisms for maintenance of increased GFR change through the trimesters of pregnancy, continuing into the postpartum period. Important causes of pregnancy-specific renal dysfunction have been further studied, but much needs to be learned. Pre-eclampsia is due to abnormal placentation, with shifts in angiogenic proteins and the renin-angiotensin-aldosterone system leading to endothelial injury and clinical manifestations of hypertension and organ dysfunction. Other thrombotic microangiopathies occurring during pregnancy have been better defined as well, with new work focusing on the contribution of the complement system to these disorders. SUMMARY Advances have been made in understanding the physiology of the kidney in normal pregnancy. Diseases that affect the kidney during pregnancy alter this physiology in various ways that inform clinicians on pathogenesis and may lead to improved therapeutic approaches and better outcomes of pregnancy.
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Cheung KL, Lafayette RA. Renal physiology of pregnancy. Adv Chronic Kidney Dis 2013; 20:209-14. [PMID: 23928384 DOI: 10.1053/j.ackd.2013.01.012] [Citation(s) in RCA: 299] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/25/2013] [Accepted: 01/30/2013] [Indexed: 11/11/2022]
Abstract
Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and fetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. The threshold for thirst and antidiuretic hormone secretion are depressed, resulting in lower osmolality and serum sodium levels. Blood pressure drops approximately 10 mmHg by the second trimester despite a gain in intravascular volume of 30% to 50%. The drop in systemic vascular resistance is multifactorial, attributed in part to insensitivity to vasoactive hormones, and leads to activation of the renin-aldosterone-angiostensin system. A rise in serum aldosterone results in a net gain of approximately 1000 mg of sodium. A parallel rise in progesterone protects the pregnant woman from hypokalemia. The kidneys increase in length and volume, and physiologic hydronephrosis occurs in up to 80% of women. This review will provide an understanding of these important changes in kidney physiology during pregnancy, which is fundamental in caring for the pregnant patient.
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14
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Early Diagnosis of Preeclampsia. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2012. [DOI: 10.1007/s13669-012-0026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Odutayo A, Hladunewich M. Obstetric Nephrology: Renal Hemodynamic and Metabolic Physiology in Normal Pregnancy. Clin J Am Soc Nephrol 2012; 7:2073-80. [DOI: 10.2215/cjn.00470112] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Complicating up to 8% of pregnancies, preeclampsia is, in fact, the most common glomerular disease worldwide. In this article, we review the effect of normal pregnancy on the kidney as well as the role of the kidney in preeclampsia. We discuss blood pressure in pregnancy and preeclampsia, followed by the physiology of hyperfiltration in normal pregnancy as well as the pathophysiology of hypofiltration and proteinuria in preeclampsia. Recent studies have suggested that the clinical syndrome of preeclampsia, which recovers rapidly after delivery of the placenta, is caused by impaired vascular endothelial growth factor signaling that disturbs the status of vascular dilatation as well as the symbiosis between the glomerular endothelium and the podocytes. Finally, we discuss the intriguing association between chronic kidney disease (CKD) and preeclampsia. We hypothesize that the imbalance between angiogenic and anti-angiogenic factors, which may be common to both preeclampsia and CKD, might explain why CKD predisposes pregnant women to develop preeclampsia.
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Mirghani RA, Elagib I, Elghazali G, Hellgren U, Gustafsson LL. Effects of Plasmodium falciparum infection on the pharmacokinetics of quinine and its metabolites in pregnant and non-pregnant Sudanese women. Eur J Clin Pharmacol 2010; 66:1229-34. [PMID: 20717655 DOI: 10.1007/s00228-010-0877-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 07/20/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE The study aimed to investigate the effects of Plasmodium falciparum infection on the pharmacokinetics of quinine and its metabolites in pregnant and non-pregnant Sudanese women. METHODS In a case-control study, nine pregnant and eight non-pregnant Sudanese women infected with P. falciparum were treated with intramuscular artemether. Before being given artemether, they received a single dose of quinine hydrochloride as intravenous infusion. Blood samples were collected frequently and analysed for quinine and its metabolites (phase I). One week later (after clearance of parasitaemia) the quinine part of the protocol was repeated (phase II). RESULTS During phase I, the AUCs (mean ± SD) of quinine and its major metaboplite, 3-hydroxyquinine, in pregnant women were 428.2 ± 132.4 and 27.8 ± 14.1 μmol l(-1) h(-1) respectively. In non-pregnant women the AUCs of quinine and 3-hydroxyquinine were 517.8 ± 100.0 and 32.3 ± 15.3 μmol l(-1) h(-1). In pregnant women the mean (90% confidence interval) AUC ratios of phase I to phase II of quinine and 3-hydroxyquinine were 1.6 (0.61, 4.22) and 1.01 (0.18, 5.60). In non-pregnant women, the AUC ratios of phase I to phase II of quinine and 3-hydroxyquinine were 1.93 (1.74, 2.15) and 1.19 (0.95, 1.47). CONCLUSIONS Plasmodium falciparum infection significantly increased plasma concentration of quinine in non-pregnant women and showed the same trend in pregnant women.
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Affiliation(s)
- Rajaa A Mirghani
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Liu X, Zhou Z, Cao Y, Wang B, Xu G. Contributions of blood pressure to proteinuria and renal function in the puerperium. Blood Press 2010; 18:362-6. [PMID: 19929283 DOI: 10.3109/08037050903312812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Increasing evidence indicates that hypertension in pregnancy plays a key role in cardiovascular disease. However, the correlation between blood pressure (BP) and proteinuria as well as renal function in the puerperium has not been established. PATIENTS We evaluated the estimated glomerular filtration rate (eGFR) and 24-h urine total protein excretion (TPE) during the second postpartum week in 852 pregnant women with normal BPs and 114 pre-eclamptic women with BPs > or =140/90 mmHg. The 852 pregnant women with normal BPs were divided into two groups based on the mean arterial pressure (MAP): 684 subjects with an MAP<90 mmHg and 168 subjects with an MAP> or =90 mmHg. RESULTS The eGFR was significantly decreased in pre-eclamptic women (112+/-41 ml/min/1.73 m(2)) compared with healthy women with an MAP<90 mmHg (131+/-35 ml/min/1.73 m(2), p<0.01) and an MAP> or =90 mmHg (128+/-34 ml/min/1.73 m(2), p<0.01), while the TPE was significantly increased compared with healthy women with an MAP<90 mmHg and an MAP> or =90 mmHg (1790+/-1422 vs 124+/-148 and 255+/-427 mg/24 h, respectively; p<0.001). Although the eGFR did not reveal a difference between the two groups of healthy women (131+/-35 vs 128+/-34 ml/min/1.73 m(2), p>0.05), the TPE was significantly higher in subjects with an MAP> or =90 mmHg than in subjects with an MAP<90 mmHg (255+/-427 vs 124+/-148 mg, p=0.004). CONCLUSIONS Pre-eclampsia induces significant renal injury characterized by an elevation of TPE and a reduction in GFR. BP is closely related to urinary protein excretion, even in healthy women (BP <140/90 mmHg) in the puerperium.
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Affiliation(s)
- Xiaowei Liu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University of the People's Liberation Army, Xi'an 710032, PR China
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Ahmed SB, Bentley-Lewis R, Hollenberg NK, Graves SW, Seely EW. A comparison of prediction equations for estimating glomerular filtration rate in pregnancy. Hypertens Pregnancy 2010; 28:243-55. [PMID: 19440935 DOI: 10.1080/10641950801986720] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare existing glomerular filtration rate (GFR) prediction equations with the gold standard, inulin clearance, in pregnancy. METHODS Five equations were assessed for precision, bias, and accuracy in prediction of true GFR, measured by inulin clearance in 12 healthy, pregnant women during the second (T2) and third (T3) trimesters and in postpartum (PP). RESULTS Precision was greatest with 24-hour creatinine clearance estimation of GFR (R(2) = 13% (T2), R(2) = 26% (T3)). Other than 100/SCr, all equations underestimated true GFR. 30% accuracy was greatest in 100/SCr (83% (T2), 92% (T3)). CONCLUSIONS Current GFR prediction formulae do not appear to be sufficient for estimating GFR in the gravid state.
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Affiliation(s)
- Sofia B Ahmed
- Division of Nephrology, Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.
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Abstract
BACKGROUND An otherwise healthy 31-year-old gravida 2 para 1 woman with a spontaneous dichorionic, diamniotic twin pregnancy presented with hypertension, nephrotic syndrome and renal insufficiency at 19 weeks' gestation. Fetal ultrasound revealed severe intrauterine growth restriction of one fetus and measurement of serum anti-angiogenic and angiogenic factors were consistent with a profound anti-angiogenic state. After one fetus died and the placenta became increasingly echogenic, the patient improved clinically, and weekly ultrasound assessments of the intact co-twin from 22 weeks onwards demonstrated symmetrical fetal growth along the 10th centile. Repeat serum angiogenic factors at 24 weeks' gestation revealed considerable improvement of the anti-angiogenic state and paralleled resolution of the clinical syndrome. INVESTIGATIONS Physical examination, laboratory evaluations including full blood count, liver function tests, electrolytes, renal function tests, screening for glomerular-based disease, 24-h urine collection for total protein, analysis of serum anti-angiogenic and angiogenic factors, fetal ultrasonography and placental Doppler examination. DIAGNOSIS Spontaneous resolution of early-onset pre-eclampsia after single fetal demise in a twin pregnancy. MANAGEMENT Labetalol was given to treat hypertension and furosemide was given as needed for edema. The patient was closely followed up throughout pregnancy in a combined nephrology/obstetrics outpatient clinic.
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Splenser AE, Fisher NDL, Danser AHJ, Hollenberg NK. Renal plasma flow: glomerular filtration rate relationships in man during direct renin inhibition with aliskiren. ACTA ACUST UNITED AC 2009; 3:315-20. [PMID: 20409974 DOI: 10.1016/j.jash.2009.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 06/11/2009] [Accepted: 06/29/2009] [Indexed: 11/28/2022]
Abstract
We examined the relation between change in renal plasma flow (RPF) and change in glomerular filtration rate (GFR) in healthy humans on a low-salt diet during direct renin inhibition with aliskiren. We measured the renal hemodynamic response to acute dosing of 300mg aliskiren by mouth to 19 healthy normotensive subjects (age, 33+/-3 years; baseline RPF, 575+/-23; GFR, 138+/-14mL/min/1.73m(2)) on a low-sodium diet (10mmol/day). GFR and RPF were measured by the clearance of inulin and para-aminohippurate. There was a marked increase in average RPF (169+/-24mL/min/1.73m(2)) and a small rise in average GFR (1.4+/-5mL/min/1.73m(2)) from baseline in response to aliskiren. There was a clear correlation between the change in RPF and the change in GFR between subjects (r=0.65; P < .003). A substantial increase in RPF was accompanied by a rise in GFR. Dependence of GFR on RPF was identified in healthy humans after RPF rose significantly with aliskiren. The responsible mechanism likely involves intravascular oncotic pressure along the glomerular capillary resulting in greater surface area available for filtration.
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Affiliation(s)
- Andres E Splenser
- Department of Radiology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Hladunewich MA, Myers BD, Derby GC, Blouch KL, Druzin ML, Deen WM, Naimark DM, Lafayette RA. Course of preeclamptic glomerular injury after delivery. Am J Physiol Renal Physiol 2008; 294:F614-20. [DOI: 10.1152/ajprenal.00470.2007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We evaluated the early postpartum recovery of glomerular function over 4 wk in 57 women with preeclampsia. We used physiological techniques to measure glomerular filtration rate (GFR), renal plasma flow, and oncotic pressure (πA) and computed a value for the two-kidney ultrafiltration coefficient ( Kf). Compared with healthy, postpartum controls, GFR was depressed by 40% on postpartum day 1, but by only 19% and 8% in the second and fourth postpartum weeks, respectively. Hypofiltration was attributable solely to depression, at corresponding postpartum times, of Kf by 55%, 30%, and 18%, respectively. Improvement in glomerular filtration capacity was accompanied by recovery of hypertension to near-normal levels and significant improvement in albuminuria. We conclude that the functional manifestations of the glomerular endothelial injury of preeclampsia largely resolve within the first postpartum month.
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