A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Abstract

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Pregnancy and Glomerular Disease

“…From this, we deduce that any active GN will potentially contribute to adverse pregnancy outcomes, and control of the glomerular disease with pregnancy-safe immunosuppression is desirable, whereas all potentially teratogenic medications must be discontinued. A reasonable approach includes treatment with pregnancy-safe immunosuppression (Immunosuppression below) to attain remission for at least 3-6 months before a pregnancy attempt (45). In patients without immunologic treatment options, control of urine protein with agents that block the RAS is the mainstay of therapy.…”

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day

“…1) [6,38,39]. Риск последовательно повышается от ХБП 1-й стадии к ХБП 5-й стадии и относительно более высок при гломерулярных, аутоиммунных заболеваниях и диабетической нефропатии [6,7,[38][39][40][41]. Исходы беременности у женщин, ставших донорами почки, позволяют предположить, что уменьшение массы почечной паренхимы ассоциировано с повышенным риском ПЭ и гипертензивных осложнений беременности [42,43].…”

“…Влияние беременности на прогрессирование ХБП не вполне ясно, поскольку дизайн, акушерская тактика и продолжительность наблюдения в проведенных исследованиях разли-чались. В целом известно, что непосредственное и отдаленное снижение функции почек, ассоции-рованное с беременностью, несвойственно ранним стадиям ХБП, но по мере усугубления тяжести ХБП риск ее прогрессирования возрастает [6,7,[38][39][40][41][44][45][46][47][48].…”

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“…The risks increase from CKD stage 1 to CKD stage 5, and may be higher in glomerular nephropathies, autoimmune diseases, and diabetic nephropathy (6,7,(38)(39)(40)(41). Results of pregnancy after kidney donation suggest that reduction of kidney parenchyma may be associated with a higher risk of PE and hypertensive disorders of pregnancy (42,43).…”