Chronic Kidney Disease

The authors discuss four common conditions in pregnant women with CKD:

  • Diabetic nephropathy—the most common and progressive nephropathy in pregnancy—is associated with preeclampsia, preterm delivery, and perinatal death. Management includes folic acid prior to conception; low-dose aspirin from the first trimester, optimization of BP control; and tight glycemic control.
  • Autosomal dominant polycystic kidney disease (ADPKD), a familial condition, can cause complications in cases of compromised renal function or pre-existing hypertension. Careful monitoring for superimposed preeclampsia and bleeding into cysts is advised.
  • Lupus nephritis can lead to extra-renal disease flares during the second and third trimester. Predictors of poor obstetric outcome include active disease at conception and in early pregnancy, hypertension, and the presence of antiphospholipid antibodies. Flares can be managed with corticosteroids (eg, azathioprine and hydroxychloroquine, which are safe during pregnancy).
  • Reflux nephropathy is associated with increased preeclampsia and hypertension. Patients should be screened regularly for urinary tract infections, and treated promptly.

Other Kidney Disorders


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The authors outline dialysis-induced risks in pregnancy, including miscarriage, intrauterine death, hypertension, superimposed preeclampsia, and preterm delivery. Predictors of poor prognosis include older age (>35 years), longer dialysis treatment (>5 years), and delayed diagnosis of pregnancy. Management involves increased frequency and duration of dialysis, optimization of BP control, and monitoring for anemia. Women with kidney transplants require special management. Recommendations of the Kidney Disease: Improving Global Outcomes (KDIGO) Guideline on Transplantation should be followed.7

Conclusion

The authors recommend “informed pre-pregnancy counseling” as essential in all patients with pre-existing kidney disease. They emphasize the importance of a multidisciplinary team, consisting of am obstetrician, a nephrologist, and other specialists as needed to provide “adequate control of hypertension and close fetal surveillance.”

References

1.  Palma-Reis I, Vais A, Nelson-Piercy C, Banerjee A. Renal disease and hypertension in pregnancy. Clin Med.2013;13(1):57-62.

2.  Lo JO, Mission JF, Caughey AB. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013;25(2):124-132.

3.  Ramin SM, Vidaeff AC, Yeomans ER, Gilstrap III LC. Chronic renal disease in pregnancy. Obstet Gynecol. 2006;108(6):1531-1539.

4.  Lindheimer MD, Taler SJ, Cunningham FG. ASH position paper: hypertension in pregnancy. J Clin Hypertens (Greenwich). 2009;11(4):214-225.

5.  Wang I-K, Muo C-H, Chan Y-C, et al. Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ. 2013;185(3):207-213.

6.  Krane NK, Hamrahian M. Pregnancy: kidney diseases and hypertension. Am J Kidney Dis. 2007;42(2):336-345.

7.  Kidney Disease Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant Work Group. 2009;9(Suppl 3):S1-S155.