Why kidneys fail post-partum: a tubulocentric viewpoint

Villié, Patricia; Dommergues, Marc; Brochériou, Isabelle; Piccoli, Giorgina Barbara; Tourret, Jérôme; Hertig, Alexandre

doi:10.1007/s40620-018-0488-0

Cited by 9 publications

(6 citation statements)

References 47 publications

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“…The postpartum period is also of pivotal importance: the acute loss of the placenta, which was a primary driver of tolerance, could theoretically trigger rejection, while the decrease of interleukin (IL)-10 and estrogen levels may counterbalance this effect [ 132 , 133 ]. Acute kidney injury (AKI) is a relatively unexplored syndrome post-partum, and new data suggest in particular to pay attention to the use of anti-fibrinolytic agents [ 134 ].…”

Section: Which Patients Are the “Best Candidates” For Pregnancy Aftermentioning

confidence: 99%

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

et al. 2018

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Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.

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Section: Which Patients Are the “Best Candidates” For Pregnancy Aftermentioning

confidence: 99%

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

et al. 2018

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“…Whatever the causes, even if proteinuria, which is one of the hallmarks of PE, is usually considered as a marker of glomerular involvement, and podocyte damage is regarded as a main pathogenetic pathway, tubular damage is probably more common than previously considered [ 46 ]. In PE and all the kidney structures may be affected, ultimately resulting in p-AKI, the common pathway of other pregnancy- related noxae, such as sepsis and shock [ 47 , 48 , 49 , 50 ] ( Table 3 , Figure 3 ). Once more, socioeconomic status is a major component of the risk of both incidence and severity [ 51 , 52 , 53 ].…”

Section: The Risk Of Aki In the Hypertensive Disorders Of Pregnancmentioning

confidence: 99%

“…Foci of acute tubular necrosis are present ( C ). Electronic microscopy shows endothelial changes ( D ) (modified from [ 47 ], with permission of the authors).…”

Section: Figurementioning

confidence: 99%

Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases

Piccoli

Zakharova

Attini

et al. 2018

JCM

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Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.

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“…We believe that this was caused by acute tubular necrosis, as this is the predominant lesion seen in postpartum kidney biopsies. If severe, PE alone is sufficient to induce acute tubular necrosis 9…”

Section: Discussionmentioning

confidence: 99%

Rapidly progressing HELLP syndrome and massive liver destruction in a 22-year-old female pregnant with monochorionic diamniotic gemelli

et al. 2020

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Haemolysis Elevated Liver parameters and Low Platelets (HELLP) syndrome can present with abdominal pain as the only symptom. It can be rapid with failure of multiple organs and is a cause of maternal death. A 22-year-old female pregnant with twins contacted her local hospital due to abdominal pain. Within 20 hours of the debut of the abdominal pain, a caesarean section was performed, the patient was re-operated due to the suspicion of abdominal bleeding. Bescause she was hypotensive and blood tests showed signs of liver destruction and acidosis, she was transferred to the intensive care unit (ICU). During an admission of 40 days, the patient received 5 plasmapheresis treatments and 10 courses of haemodialysis. CT scans showed massive liver haematomas intraparenchymal and subcapsular. The CT scan images are very interesting and included in the case report.This case presents a good prognosis after a rapid progression of HELLP in spite of a dramatic clinical presentation. This topic is of great interest to a wide spectre of clinicians, as an early multidisciplinary approach is necessary.

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Why kidneys fail post-partum: a tubulocentric viewpoint

Cited by 9 publications

References 47 publications

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases

Rapidly progressing HELLP syndrome and massive liver destruction in a 22-year-old female pregnant with monochorionic diamniotic gemelli

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