Diabetic Nephropathy and Microalbuminuria in Pregnant Women With Type 1 and Type 2 Diabetes

Damm, Julie Agner; Àsbjörnsdóttir, Björg; Callesen, Nicoline; Mathiesen, Jesper Mosolff; Ringholm, Lene; Pedersen, Birgith; Mathiesen, Elisabeth R.

doi:10.2337/dc13-1031

Cited by 61 publications

(55 citation statements)

References 38 publications

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“…This is in contrast to our previous observations in other type 1 diabetes patients [25] and the Finnish background population, in which every third parturient is currently overweight and 13% are obese [26]. The frequency of smoking during pregnancy was higher than the 15-17% recorded in 1987-2010 for all Finnish parturients [27], but similar to the figures reported by Damm et al [4]. There is a need to intensify the antismoking counselling given to reproductive-age women with diabetic nephropathy, as smoking may promote the development of diabetic renal disease [28].…”

Section: Discussionsupporting

confidence: 69%

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Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988–2011

et al. 2015

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Aims/hypothesis Our aim was to analyse possible changes in the glycaemic control, BP, markers of renal function, and obstetric and perinatal outcomes of parturients with diabetic nephropathy during 1988-2011. Methods The most recent childbirth of 108 consecutive type 1 diabetes patients with diabetic nephropathy and a singleton pregnancy were studied. Two periods, 1988Two periods, -1999Two periods, and 2000Two periods, -2011 . Antihypertensive medication usage increased before pregnancy (34% vs 65%, p=0.002) and in the second and third trimesters of pregnancy (25% vs 47%, p=0.02, and 36% vs 60%, p =0.01, respectively). BP exceeded 130/ 80 mmHg in 62% and 61% (p=0.87) of patients in the first trimester, and in 95% and 93% (p=0.69) in the third trimester, respectively. No changes were observed in the markers of renal function. Pre-eclampsia (52% vs 42%, p=0.29) and preterm birth rates before 32 and 37 gestational weeks (14% vs 21%, p=0.33, and 71% vs 77%, p=0.49, respectively) remained high. The elective and emergency Caesarean section rates were 71% and 45% (p=0.01) and 29% and 48% (p= 0.05), respectively. Neonatal intensive care unit admissions increased from 26% to 49% (p=0.02). Conclusions/interpretation Early pregnancy glycaemic control and hypertension management were suboptimal in both time periods. Pre-eclampsia and preterm delivery rates remained high in patients with diabetic nephropathy.

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Section: Discussionsupporting

confidence: 69%

“…Diabetic nephropathy, which complicates 2.5-5% of type 1 diabetes pregnancies [3,4], is associated with a particularly high risk of hypertensive disorders of pregnancy, preterm birth, intrauterine growth restriction and perinatal mortality [4][5][6][7][8][9][10][11][12][13][14].…”

Section: Introductionmentioning

confidence: 99%

Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988–2011

et al. 2015

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“…The treatment goal was a blood pressure below 135/85 mmHg and urinary albumin excretion below 300 mg/24 h. If the woman was receiving antihypertensive treatment prior to pregnancy, the treatment was shifted to pregnancy-friendly drugs such as methyldopa without interruption in antihypertensive treatment. In our most recent publication, average blood pressure in both early and late pregnancy were approximately 128/70 mmHg, both in women with microalbuminuria and in those with diabetic nephropathy, and only one out of 41 women with kidney involvement developed nephrotic proteinuria [7]. The study also included women with type 2 diabetes, and women with kidney involvement showed similar pregnancy outcomes, regardless of type of diabetes.…”

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confidence: 99%

“…Our group in Copenhagen has published data on several small population-based series of pregnant women with kidney involvement (such as microalbuminuria or diabetic nephropathy) who were given early and intensive antihypertensive treatment, mainly methyldopa and labetalol, for blood pressure reduction [5][6][7]. The treatment goal was a blood pressure below 135/85 mmHg and urinary albumin excretion below 300 mg/24 h. If the woman was receiving antihypertensive treatment prior to pregnancy, the treatment was shifted to pregnancy-friendly drugs such as methyldopa without interruption in antihypertensive treatment.…”

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confidence: 99%

“…The study also included women with type 2 diabetes, and women with kidney involvement showed similar pregnancy outcomes, regardless of type of diabetes. In women with type 1 diabetes and nephropathy from the two cohorts, one out of seven and three out of 11, respectively [6,7] delivered before week 34, giving a prevalence of early preterm delivery of 22% in population-based samples from Copenhagen. Whether this reflects a better outcome than the prevalence of preterm delivery before week 32 in the study of Klemetti et al [1] is an open question, but prevention of severe hypertension and severe nephrotic proteinuria is probably beneficial for the mother.…”

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confidence: 99%

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Diabetic nephropathy in pregnancy: new insights from a retrospective cohort study

Mathiesen

2015

Diabetologia

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In this issue of Diabetologia, Klemetti and colleagues [1] present the results of the largest evaluation of clinical care in pregnant women with type 1 diabetes and diabetic nephropathy ever. This paper adds knowledge about the outcome, in present time, of these diabetic patients. The study is population based and covers more than 100 pregnant women with type 1 diabetes and nephropathy. A careful and proper evaluation of patient records was conducted, and the paper comes from a well-known centre with a long tradition for research and development within the field of diabetes and pregnancy.The good news is that the perinatal mortality rate is reported to be 3% for these patients. This rate is comparable with that for diabetic patients without kidney involvement [2]. Advancements in ultrasound fetal flow measurements may have contributed to the prevention of stillbirths, and the intensification of the care of preterm infants may have contributed to the prevention of early neonatal deaths. The chance of women with diabetic nephropathy having a 'take home baby' is thus very high. Other studies have demonstrated that the risk of pregnancy-induced deterioration of diabetic nephropathy is low if women enter the pregnancy with a serum creatinine level <200 μmol/l [3], and only one woman received dialysis treatment in the present cohort of pregnant women [1].This paper provides further evidence that intensive antihypertensive treatment during pregnancy is probably beneficial in these vulnerable women. Preterm delivery before 32 weeks was seen in 21% of the cases in this cohort during 2000-2011, and preterm delivery before 37 weeks was very common (>70%), mainly due to severe hypertensive disorders. This leaves room for improvement. The majority of women in the present cohort did not receive antihypertensive treatment in early pregnancy. This strategy is often appropriate in women with mild essential hypertension, and is recommended in many international guidelines for antihypertensive treatment in pregnancy. The main reasons for this recommendation are that antihypertensive treatment may induce fetal growth restriction and that it is desirable to limit the use of medications that pass the placenta to the fetus. However, this may not be an effective approach in women with severe hypertension and kidney involvement, such as women with diabetic nephropathy. Blood pressure was within the target of 130/80 mmHg in only 39% of the cohort in early pregnancy, and a high proportion developed severe hypertension with a high level of nephrotic proteinuria in late pregnancy.In logistic regression analysis, first trimester blood pressure above 130/80 mmHg and the last HbA 1c before delivery were associated with preterm birth before 37 gestational weeks. Furthermore, total urine protein excretion in the second and third trimesters correlated negatively with gestational age at birth. This paper thus supports the notion that in addition to the impact of poor glycaemic control uncontrolled hypertension might also contribute to the high pre...

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