Chronic kidney disease in pregnancy and fetomaternal outcome
Keywords:Acute kidney failure, Cardiac failure, Obstetric nephrology, Pregnancy, Premature, Stillbirth
Background: Chronic kidney disease is a heterogeneous group of renal dysfunctions with complex and varied presentations in pregnancy. With a long asymptomatic course, timely diagnosis and management is crucial for fetomaternal wellbeing.
Methods: A retrospective cohort study over a period of 3 years and 4 months included all obstetric in patients with known or newly diagnosed renal disorders. Maternal outcome was measured with regard to biochemical parameters presence /absence of proteinuria, hypertension, mode of pregnancy termination and complications. Fetal outcome was noted with respect to antenatal complications, weight, Apgar, NICU stay. Computation of results was done using percentages, mean and proportions.
Results: Out of 13 women studied, 53.8% were pre-diagnosed cases of renal dysfunction and 46.2% were diagnosed during pregnancy. 38% had proteinuria at first visit and 50% remained so even after delivery. 60% had history of pregnancy induced hypertension in their previous pregnancies. Secondary hypertension and superimposed preeclampsia were seen in 30% and 38% cases respectively, with only one patient requiring magnesium sulphate prophylaxis in post-partum. Cardiac dysfunction was found to be coexisting in 15.3% cases with pre-existing renal leision. Intrauterine growth restriction was seen in 61.5% cases Average fetal weight was 2. 26kg with 30% having NICU stay. 30.6% had preterm delivery. Mode of delivery was caesarean section in 46% cases.
Conclusions: Pregnancy with CKD is a high-risk pregnancy with adverse fetomaternal outcomes. For optimal pregnancy outcomes, an expert multidisciplinary team is required. With limited studies in south Asian population, there needs to be an upgradation in registry system.
Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis. 1999;33(2):235-52.
Nevis IF, Reitsma A, Dominic A, McDonald S, Thabane L, Akl EA, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol. 2011;6(11):2587-98.
Nevis IF, Reitsma A, Dominic A, McDonald S, Thabane L, Akl EA, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol. 2011;6(11):2587-259.
Piccoli GB, Attini R, Vasario E, Conijn A, Biolcati M, D'Amico F, Consiglio V, et al. Pregnancy and chronic kidney disease: a challenge in all CKD stages. In J Am Soc Nephrol. 2010;5(5):844-55.
Hui D, Hladunewich MA. Chronic kidney disease and pregnancy. Obstet Gynecol. 2019;133(6):1182-94.
Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, et al. 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. J Clin Med. 2018;7(11):415.
Piccoli GB, Attini R, Vasario E, Conijn A, Biolcati M, D'Amico F, et al. Pregnancy and chronic kidney disease: a challenge in all CKD stages. Clin J Am Soc Nephrol. 2010;5(5):844-55.
Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease - a systematic review and meta-analysis. PLoS One. 2016;11(7):e0158765.
Barrett PM, McCarthy FP, Kublickiene K, Evans M, Cormican S, Judge C, et al. Adverse pregnancy outcomes and long-term risk of maternal renal disease: a systematic review and meta-analysis protocol. BMJ Open. 2019;9(5):e027180.
Anand S, Shivashankar R, Ali MK, Kondal D, Binukumar B, Montez-Rath ME, et al. Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease. Kidney Int. 2015;88(1):178-85.
Anupama YJ, Uma G. Prevalence of chronic kidney disease among adults in a rural community in South India: results from the kidney disease screening (KIDS) project. Indian J Nephrol. 2014;24(4):214.
Singh NP, Ingle GK, Saini VK, Jami A, Beniwal P, Lal M, et al. Prevalence of low glomerular filtration rate, proteinuria and associated risk factors in North India using Cockcroft-gault and modification of diet in renal disease equation: an observational, cross-sectional study. BMC Nephrol. 2009;10:4.
Varma PP, Raman DK, Ramakrishnan TS, Singh P, Varma A. Prevalence of early stages of chronic kidney disease in apparently healthy central government employees in India. Nephrol Dial Transplant. 2010;25(9):3011-7.
Zhang JJ, Ma XX, Hao L, Liu LJ, Lv JC, Zhang H. A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy. Clin J Am Soc Nephrol. 2015;10(11):1964-78.
El Hafeez SA. Non-steroidal anti-inflammatory drugs among chronic kidney disease patients: an epidemiological study. J Egypt Public Health Assoc. 2019;94(1):8.
Drueke TB, Parfrey PS. Summary of the KDIGO guideline on anemia and comment: reading between the (guide)line(s). Kidney Int. 2012;82:952-60.
Roberts M, Lindheimer MD, Davison JM. Altered glomerular perms selectivity to neutral dextrans and heteroporous membrane modeling in human pregnancy. Am J Physiol. 1996;270:F338.
Vellanki K. Pregnancy in chronic kidney disease. Adv Chronic Kidney Dis. 2013;20(3):223-8.
Nee PA, Bailey DJ, Todd V, Lewington AJ, Wootten AE, Sim KJ. Critical care in the emergency department: acute kidney injury. Emerg Med J. 2016;33(5):361-5.
Krane NK. Acute renal failure in pregnancy. Arch Intern Med. 1988;148(11):2347-57.
Schokker SA, Van Oostwaard MF, Melman EM, Van Kessel JP, Baharoglu MI, et al. Cerebrovascular, cardiovascular and renal hypertensive disease after hypertensive disorders of pregnancy. Pregnancy Hypertens. 2015;5(4):287-93.
Imbasciati E, Gregorini G, Cabiddu G, Gammaro L, Ambroso G, Del Giudice A. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes. Am J Kidney Dis. 2007;49(6):753-62.
Bowe B. Changes in the US burden of chronic kidney disease from 2002 to 2016: an analysis of the global burden of disease study. JAMA Netw Open. 2018;1(7):e184412.
Pillay C, Clark K. Postpartum care of women with renal disease. Best Pract Res Clin Obstet Gynaecol. 2019;pii:S1521-6934(19)30021-5.
Dumanski SM, Ahmed SB. Fertility and reproductive care in chronic kidney disease. J Nephrol. 2019;32(1):39-50.
Crump C, Sundquist J, Winkleby MA, Sundquist K. Preterm birth and risk of chronic kidney disease from childhood into mid-adulthood: national cohort study. BMJ. 2019;365:l1346.
Abitbol CL, Rodriguez MM. The long-term renal and cardiovascular consequences of prematurity. Nat Rev Nephrol. 2012;8:265-74.
Abitbol CL, DeFreitas MJ, Strauss J. Assessment of kidney function in preterm infants: lifelong implications. Pediatr Nephrol. 2016;31:2213-22.
Seema C. Pregnancy in chronic renal insufficiency: single center experience from North India. Arch Gynecol Obstet. 2009;279:691.
Garlo K. Severity of anemia predicts hospital length of stay but not readmission in patients with chronic kidney disease: a retrospective cohort study. Medicine (Baltimore). 2015;94(25):e964.
Hildegard Stancu S. Renal anemia and hydration status in non-dialysis chronic kidney disease: Is there a link. J Med Life. 2018;11(4):293-8.
Kuragano T, Mizusaki K, Kimura T, Nakanishi T. Anemia management considering the pathophysiology of elderly chronic kidney disease patients. Contrib Nephrol. 2019;198:135-43.
K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39:S1-S266.
Hasan M, Sutradhar I, Gupta RD, Sarker MM. Prevalence of chronic kidney disease in South Asia: a systematic review. BMC Nephrol. 2018;19(1):291.
Amador-Martínez. Reduced endothelial nitric oxide synthase activation contributes to cardiovascular injury during chronic kidney disease progression. Am J Physiol Renal Physiol. 2019.
Izumaru K. Reduced estimated GFR and cardiac remodeling: a population-based autopsy study. Am J Kidney Dis. 2019.
Misra R. Pregnancy with chronic kidney disease: Outcome in Indian women. J Women Health. 2004;12:1019-25.
O'Shaughnessy MM. Pregnancy outcomes in patients with glomerular disease attending a single academic center in North Carolina. Am J Nephrol. 2017;45(5):442-51.
Laurichesse Delmas H. Congenital unilateral renal agenesis: prevalence, prenatal diagnosis, associated anomalies. Data from two birth-defect registries. Birth Defects Res. 2017;109(15):1204-11.
Steele SE, Terry JE, Page LM, Girling JC. Pregnancy in women known to be living with a single kidney. Obstet Med. 2019;12(1):22-6.