Pregnancy, Proteinuria, Plant-Based Supplemented Diets and Focal Segmental Glomerulosclerosis: A Report on Three Cases and Critical Appraisal of the Literature

Abstract

Chronic kidney disease (CKD) is increasingly recognized in pregnant patients. Three characteristics are associated with a risk of preterm delivery or small for gestational age babies; kidney function reduction, hypertension, and proteinuria. In pregnancy, the anti-proteinuric agents (ACE–angiotensin converting enzyme-inhibitors or ARBS -angiotensin receptor blockers) have to be discontinued for their potential teratogenicity, and there is no validated approach to control proteinuria. Furthermore, proteinuria usually increases as an effect of therapeutic changes and pregnancy-induced hyperfiltration. Based on a favourable effect of low-protein diets on proteinuria and advanced CKD, our group developed a moderately protein-restricted vegan-vegetarian diet tsupplemented with ketoacids and aminoacids for pregnant patients. This report describes the results obtained in three pregnant patients with normal renal function, nephrotic or sub-nephrotic proteinuria, and biopsy proven diagnosis of focal segmental glomerulosclerosis, a renal lesion in which hyperfiltration is considered of pivotal importance (case 1: GFR (glomerular filtration rate): 103 mL/min; proteinuria 2.1 g/day; albumin 3.2 g/dL; case 2: GFR 86 mL/min, proteinuria 3.03 g/day, albumin 3.4 g/dL; case 3: GFR 142 mL/min, proteinuria 6.3 g/day, albumin 3.23 g/dL). The moderately restricted diet allowed a stabilisation of proteinuria in two cases and a decrease in one. No significant changes in serum creatinine and serum albumin were observed. The three babies were born at term (38 weeks + 3 days, female, weight 3180 g-62th centile; 38 weeks + 2 days, female, weight 3300 g-75th centile; male, 38 weeks + 1 day; 2770 g-8th centile), thus reassuring us of the safety of the diet. In summary, based on these three cases studies and a review of the literature, we suggest that a moderately protein-restricted, supplemented, plant-based diet might contribute to controlling proteinuria in pregnant CKD women with focal segmental glomerulosclerosis. However further studies are warranted to confirm the potential value of such a treatment strategy.

Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes

“…Then, they followed a moderately restricted plant-based diet with a protein intake of 0.6-0.8 g/kg per day, plus essential amino acids and ketoacids supplements. Remarkably, the adoption of this diet was associated with stabilization or a reduction of proteinuria, without modifications in renal function and serum albumin, while the three babies were born at term, without major issues [35]. An interesting anecdotical experience comes from a Mexican group.…”

“…The authors, admitting the uniqueness of the case report, underlined the importance of compliance and self-empowerment, especially in developing countries, where CKD pregnant patients have to face clinical, economic and logistic challenges, and confirm the safety of the plant-based supplemented diets in pregnancy. Regarding the possible protective mechanisms of low protein diet, especially if supplemented with amino acids and ketoacids, it has been proposed that this kind of diet may contribute to improve uteroplacental circulation and reduce pregnancy-related glomerular hyperfiltration, allowing more babies to reach a later pregnancy stage and reducing the CKD progression rate [35]. In addition, a low protein diet could reduce oxidative stress and protect against endothelial dysfunction, as it has been shown in some experimental models (5/6 nephrectomized rats) [37].…”

Collapsing Lesions and Focal Segmental Glomerulosclerosis in Pregnancy: A Report of 3 Cases

“…In pregnancy, the short-term prognosis in forms secondary to hyperfiltration may be favorable, but less is known about collapsing lesions, which usually have a poor prognosis outside of pregnancy. 13,15,25,26 We report 3 patients who developed collapsing lesions in pregnancy, in 2 cases presumably superimposed on preexisting FSGS lesions (long-lasting kidney disease was suggested by ultrasonography and kidney biopsy results) and in 1 case apparently without previous pathology. These reports, observed in 2015 to 2018, suggest that the onset of collapsing lesions should be considered in patients with FSGS who have a brisk increase in serum creatinine (Scr) level or proteinuria in pregnancy, and that these lesions can respond well to treatment.…”

“…[1][2][3][4][5][6][7][8][9][10] Conversely, pregnancy in patients with already diagnosed FSGS is known to have a higher risk for complications, including preeclampsia, preterm delivery, and increases in proteinuria. [11][12][13][14][15][16] Hyperfiltration stress, which is likely to increase in pregnancy, has been identified as a potential, albeit not confirmed, risk factor for the development of an overt clinical picture of FSGS. This can be an issue in women born with very low birth weight, a population known to have a reduced nephron number and to be particularly prone to developing FSGS.…”

Study of Preeclampsia in Placenta, Kidney, and Hepatic Diseases

“…Tempol, a mimetic dismutase-antioxidant drug has been shown to weaken radical damage, exert beneficial effects on animal models of oxidative stress and hypertension, against chronic ischemic renal injury, and prevent renal dysfunction through antioxidants, vasodilators, and antihypertensive [145]. In addition, the plant-based diet should be limited, especially those containing proteins in PE patients, as it can control proteinuria in pregnant CKD women with segmental focal glomerulosclerosis [146].…”