Impact of chronic kidney disease on fetomaternal outcome: a case report

Chronic kidney disease is a heterogenous group of disorders resulting from anatomical and physiological alterations in the kidney. Pregnancy might accelerate the renal disease-causing progression of renal failure, development of preeclampsia, anemia. This increases the risk of adverse fetomaternal outcomes including prematurity, fetal growth restriction, fetal deaths and development of hypertension, nephrotic syndrome, renal failure in the mother. Chronic kidney disease affects approximately 3% of pregnant women. This study was carried out to assess the course of chronic kidney disease in pregnancy and the effect it has on the fetal outcome. A case of chronic kidney disease presenting to the OBGY emergency unit was studied. a detail history was taken and examination was done. Baseline antenatal investigations were carried out. Special tests including renal Doppler, ophthalmoscopic examination, ECG, were done to assess the renal function. Treatment was started for control of hypertension and further progression of the disease. Pregnancy has adverse outcome when associated with acute kidney injury. Maternal hypertension and proteinuria are the major predisposing factors. Prematurity is one of the commonest fetal complications apart from growth restriction. Chronic kidney disease in pregnancy requires a multidisciplinary approach involving experienced obstetricians, nephrologists, radiologists, intensivists and neonatologists. The etiology, degree of renal dysfunction, development of additional obstetric complications determines the prognosis. Supportive therapy in the early course of the disease and timely definitive management as per the etiology is found to improve the feto-maternal outcome.

Pregnancy in dialysis patients: a case series

Fertility is markedly reduced in patients with chronic renal failure. For women with pre-existing renal disease, pregnancy is associated with an increased rate of fetal complications and a considerable risk of renal disease progression. Due to substantial improvements in antenatal and neonatal care, fetal outcome has improved considerably in the last two decade

Maternal, pregnancy and fetal outcomes in de novo anti-glomerular basement membrane antibody disease in pregnancy: A systematic review

Background Outside of pregnancy, anti-glomerular basement membrane (GBM) antibody disease is associated with significant morbidity and mortality. However, there is limited knowledge regarding de novo anti-GBM disease in pregnancy. Methods A systematic review was performed to identify maternal, pregnancy and fetal outcomes in de novo anti-GBM disease in pregnancy. Studies were selected from PubMed, EMBASE, Cochrane Library databases and conference proceedings, without language restriction. Results Data from eight patients were derived from seven case reports and one unpublished case. Most (6/8) patients presented after the first trimester. During pregnancy, acute kidney injury (5/8), anemia (5/8), hematuria (8/8) and proteinuria (8/8) were common. When hemodialysis was required antepartum (5/8), renal function recovery to independence of renal replacement was unlikely (2/5). While pulmonary involvement was common (5/8), no permanent damage was reported (0/8). The majority of cases ended in live births (6/8) although prematurity (6/6), intrauterine growth restriction (2/6), small for gestational age (4/6) and complications of prematurity (1/6) were common. When anti-GBM levels were tested in the living newborn, they were detectable (2/5), but no newborn renal or lung disease was reported (0/6). Complications in pregnancy included gestational diabetes (3/8), hyperemesis gravidarum (2/8) and preeclampsia (2/8). Conclusions Live births can be achieved in de novo anti-GBM disease in pregnancy, but are commonly associated with adverse maternal, pregnancy and fetal outcomes. Only with awareness of common presentations, and management strategies can outcomes be optimized

The problem of pregnancy complicated by chronic kidney disease

Chronic kidney disease (CKD) in high-risk pregnancies is a challenge for multidisciplinary teams of doctors. Due to the fact that the disease affects both the mother and the fetus, and the course of the pregnancy. The following article reviews the literature about the interaction between pregnancy and CKD and dialysis therapy. Even pregnancy itself can lead to a worsening of kidney dysfunction. The risk of this consequence increases with the degree of renal failure, therefore renal parameters and other pregnancy test results should be monitored. On the other hand, the most common complications of chronic kidney disease in pregnancy described in the literature include pre-eclampsia, preterm labor, intrauterine growth restriction (IUGR) or low birth weight, surgical delivery by caesarean section and miscarriage. Dialysis therapy also leads to abnormalities in the course of pregnancy, and patients require constant monitoring during its course. Attention is also drawn to the high percentage of newborns requiring intensive postpartum care. Due to the risk for the fetus and mother mentioned in the article, nephrologists and gynecologists should cooperate closely from the pre-contraceptive period in order to reduce the risk of sequelae and better control of the underlying disease

Health outcomes of children born to mothers with chronic kidney disease: a pilot study

This study aimed to study the health of children born to mothers with chronic kidney disease. Twenty-four children born to mothers with chronic kidney disease were compared with 39 matched control children born to healthy mothers without kidney disease. The well-being of each child was individually assessed in terms of physical health, neurodevelopment and psychological health. Families participating with renal disease were more likely to be from lower socio-economic backgrounds. Significantly fewer vaginal deliveries were reported for mothers with renal disease and their infants were more likely to experience neonatal morbidity. Study and control children were comparable for growth parameters and neurodevelopment as assessed by the Griffiths scales. There was no evidence of more stress amongst mothers with renal disease or of impaired bonding between mother and child when compared to controls. However, there was evidence of greater externalizing behavioral problems in the group of children born to mothers with renal disease. Engaging families in such studies is challenging. Nonetheless, families who participated appreciated being asked. The children were apparently healthy but there was evidence in this small study of significant antenatal and perinatal morbidity compared to controls. Future larger multi-center studies are required to confirm these early findings

Systemic lupus erythematosus-a good maternal and fetal outcome

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease which primarily affects women in their reproductive years. The fertility is generally unaffected except in women with active disease, significant impairment of renal function, or high dose corticosteroid or cyclophosphamide therapy, which can result in ovarian dysfunction. This case report elaborates on the course of the pregnancy and the favourable maternal and fetal obstetric outcome of a 28-year-old female with known case of hypothyroidism who presented with chief complaints of generalised swelling all over the body and exertional dyspnoea and was later diagnosed to be a case of focal proliferative lupus nephritis, class III (ISN/RPS) on renal biopsy done postpartum. The effect of pregnancy on maternal disease is controversial. While some studies report exacerbation of SLE during pregnancy,others have not reported increased flares. The only study on this aspect of SLE from our country did not report a flare-up of disease during pregnancy

Pregnancy and the kidneys

Renal disease in pregnancy may cause a feeling of trepidation, even in the most experienced physician. However, before disease can be established, it is important to understand the substantial physiological changes that may occur during a normal pregnancy. Renal disease may take several forms and pregnancy may be the first medical review for women with a previously undiagnosed renal problem. Patients may have pre-existing renal disease, e.g. diabetic nephropathy. Additionally, women with renal transplants and renal diseases, e.g. lupus nephritis, require immunosuppression. Hypertensive disorders of pregnancy, including pre-eclampsia, are the commonest medical complications in pregnancy, and remain the most prevailing direct cause of maternal mortality in South Africa (SA). Both pre-existing hypertension and renal disease increase the risk of pre-eclampsia, which predisposes to preterm delivery, and maternal morbidity and mortality. Pregnancy outcomes in renal disease are determined by baseline creatinine levels, hypertension and degree of proteinuria. The risk of progression of chronic kidney disease increases as renal function worsens. In SA, this is complicated by restricted access to dialysis in the state sector. To ensure the best outcome for mother and child, pre-pregnancy counselling and review of medication are essential. Renal patients and those with hypertension are at high risk of complications, and regular antenatal assessments by a multidisciplinary team are required to monitor blood pressure, proteinuria, diabetes control and fetal wellbeing.

Alport's Syndrome in Pregnancy

Background. Alport's syndrome is an X-linked hereditary disorder affecting the glomerular basement membrane associated with ocular and hearing defects. In women, the disease is much less severe compared to that in men. However, women with Alport's syndrome can have an accelerated form of their disease during pregnancy with worsening of kidney function and can also develop preeclampsia. There are only four described cases of Alport's syndrome in pregnancy. Case Presentation. 20-year-old woman with a history of Alport's syndrome, which during pregnancy worsened resulting in hypertension, proteinuria, and acute kidney injury. Fortunately, there was complete resolution of the proteinuria and kidney injury with delivery, and the patient did not require any renal replacement therapy. Conclusion. One of the four reported cases had an accelerated form of the disease during pregnancy with rapid progression of kidney injury and end-stage renal disease. There are no definite guidelines to monitor these patients during pregnancy. Further studies are required to understand the exact pathophysiology of kidney damage that occurs in pregnant women with Alport's syndrome. This may give us some insight into the prognostic predictors, so that we can monitor these women more thoroughly and prevent adverse outcomes

Lupus nephritis management guidelines compared

In the past years, many (randomized) trials have been performed comparing the treatment strategies for lupus nephritis. In 2012, these data were incorporated in six different guidelines for treating lupus nephritis. These guidelines are European, American and internationally based, with one separate guideline for children. They offer information on different aspects of the management of lupus nephritis including induction and maintenance treatment of the different histological classes, adjunctive treatment, monitoring of the patient, definitions of response and relapse, indications for (repeat) renal biopsy, and additional challenges such as the presence of vascular complications, the pregnant SLE patient, treatment in children and adolescents and considerations about end-stage renal disease and transplantation. In this review, we summarize the guidelines, determine the common ground between them, highlight the differences and discuss recent literature

A case report on IgA nephropathy in pregnancy

IgA Nephropathy is a primary glomerular disease leading cause of primary glomerulonephritis and one of the important  leading cause of secondary hypertension. Pregnancy causes complex pathological changes in patients with IgA nephropathy affecting the renal function leading to secondary hypertension which in turn affects the prognosis of these patients. The association between chronic kidney disease and increased risk of adverse maternal and fetal outcomes which includes pre-eclampsia, accelerated decline in renal function, intrauterine growth retardation, preterm delivery and fetal death, is well recognised. Management of patients with IgA Nephropathy in pregnancy is challenging and thus authors are discussing here a case with successful outcome. Our patient was a known case of IgA Nephropathy and landed up with complications during pregnancy which was manged successfully.