Pregnancy and advanced chronic kidney disease
GESTACIÓN EN ENFERMEDAD RENAL CRÓNICA AVANZADA.
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class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Obstetricia y Ginecología, Hospital del Henares, Coslada, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "GESTACIÓN EN ENFERMEDAD RENAL CRÓNICA AVANZADA." ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10354_18030_5954_en_figure1.jpg" "Alto" => 327 "Ancho" => 519 "Tamanyo" => 127973 ] ] "descripcion" => array:1 [ "en" => "Laboratory parameters progression over the follow-up period. Follow-up at 3 months after the beginning of pregnancy and then monthly." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> Dear Editor, </span> </p><p class="elsevierStylePara"> The ability to become and remain pregnant in patients with chronic kidney disease depends on its stage. In early stages of the disease, there are practically no differences from a normal pregnancy.<span class="elsevierStyleSup">1 </span>On the other hand, the difficulties that pregnancy poses to renal replacement therapy (RRT) are well known, and better outcomes have been described in patients who have undergone renal transplantation.<span class="elsevierStyleSup">2 </span>However, the presence of advanced chronic kidney disease (stage 3-4) and pregnancy is an uncommon occurrence. Here we present the progression and treatment of a pregnant woman with stage 4 chronic kidney disease, which is especially unusual. </p><p class="elsevierStylePara"> The patient is a 23-year-old female with epilepsy and chronic renal failure secondary to interstitial nephropathy. She was not hypertensive and presented, at one month of gestation, with the following laboratory findings: Hb: 13.1g/dl, Cr: 2.7mg/dl, urea: 101mg/dl, Ca: 9.1, P: 3.8mg/dl, HCO3: 19mmol/l, PTH: 480pg/ml, estimated glomerular filtration rate (eGFR) (MDRD- 4): 21ml/min/1.73m<span class="elsevierStyleSup">2</span>, proteinuria: 2.23g/day; other tests without significant abnormalities. Weight 45.8kg and blood pressure (BP) 113/75mmHg. The progression of laboratory values can be seen in Figure 1. Clinical progression, BP control, presence of urea less than 100mg/dl or serum creatinine less than 4mg/dl, and ultrasound follow-up were established as the parametres to be assessed at the beginning of the RRT. These values remained within established limits throughout the pregnancy, with acceptable foetal progression until the eighth month. At that time, increased blood pressure (136/91), the presence of oedema, significant weight gain, and a mild increase in creatinine were noted. At 34+4 weeks, induction of labour was decided on for intrauterine growth restriction. During her admission she required treatment with labetalol due to increased BP. No haematologic or hepatic abnormalities were evident at any point. The neonate weighed 1,640g (3-10 percentile) and had respiratory distress consistent with hyaline membrane disease. Later, the neonate showed signs of persistent ductus arteriosus that required surgical closure. At 23 days of age, the infant was discharged with progressive weight gain and normal development to date. Three months after delivery, the mother was asymptomatic, with BP: 139/89, weight: 49.3 and Hb: 11.4, Cr: 5.5, urea: 137, and eGFR: 9, awaiting RRT initiation. </p><p class="elsevierStylePara"> The association of advanced chronic kidney disease (CKD) and pregnancy is a rare event, with an incidence between 0.002 and 0.01% depending on the series.<span class="elsevierStyleSup">3 </span>Decreased fertility, and the general tendency to discourage pregnancy in these stages, result in this low incidence.<span class="elsevierStyleSup">4 </span>In turn, it is accepted that pregnancy at early stages, with eGFR greater than 60ml/min/1.73m<span class="elsevierStyleSup">2</span>, does not alter the course of the renal disease and foetal viability is similar to women without chronic kidney disease.<span class="elsevierStyleSup">1 </span>Outcomes in more advanced stages are not as clearly defined. In the largest collected series of 49 women with advanced CKD, stage 3-4, it was found that eGFR less than 40ml/min/1.73m<span class="elsevierStyleSup">2 </span>and proteinuria greater than 1g/day at the start of pregnancy led to greater reduction in renal function and increased foetal morbidity and mortality.<span class="elsevierStyleSup">4 </span>In another series, up to 10% of patients progressed to ESRD after pregnancy.<span class="elsevierStyleSup">5 </span>On the other hand, estimation of renal function in pregnant women is not well defined. It is accepted that the formulas for estimating glomerular filtration rate are not adjusted for this cases<span class="elsevierStyleSup">6 </span>and, at the same time, there are no clear indications for starting RRT in these situations. Some authors have set serum creatinine values between 3.5 and 4mg/dl for starting RRT.<span class="elsevierStyleSup">1 </span>Other more recent studies in patients on haemodialysis have reported better results, with urea levels less than 100mg/dl.<span class="elsevierStyleSup">7,8 </span>Although there is no firm evidence to support this, those values were set as limits in our patient. Renal function deteriorated, but did not exceed the limits that had been set, and thus it was not necessary to start RRT. At the same time, the presence of preeclampsia in these patients is also increased.<span class="elsevierStyleSup">4 </span>However, the increase in BP and proteinuria in pregnant women makes it difficult to differentiate it from an exacerbation of the baseline disease.<span class="elsevierStyleSup">3 </span>In our case we observed an increase in proteinuria and BP in the last trimester. The absence of hepatic or haematologic involvement could indicate a course related to the renal disease in the context of gestational changes. </p><p class="elsevierStylePara"> From the neonatal perspective, although improvements in the paediatric intensive care have improved prognosis, the described mortality rate is between 4 and 4.9%, higher than in the normal population.<span class="elsevierStyleSup">4 </span>The most common foetal complications are intrauterine growth restriction, low birth weight and preterm delivery.<span class="elsevierStyleSup">5 </span>The association of proteinuria exceeding 1g/day and eGFR of less than 40 are risk factors for development.<span class="elsevierStyleSup">4 </span>In our case there was intrauterine growth restriction in the final phase of pregnancy and low birth weight, complications associated with high morbidity. The presence of hyaline membrane syndrome and persistent ductus arteriosus is associated with premature birth, but we are unable to establish that role that renal disease plays in their development. In short, pregnancy is uncommon at stages 3-4; the association of proteinuria and an advanced renal stage implies a greater likelihood of renal disease and foetal morbidity. The approach that should be followed is based on recommendations and, although no guidelines exist regarding this, it seems reasonable to set the described parameters for monitoring purposes. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><a href="grande/10354_18030_5954_en_figure1.jpg" class="elsevierStyleCrossRefs"><img src="10354_18030_5954_en_figure1.jpg" alt="Laboratory parameters progression over the follow-up period. Follow-up at 3 months after the beginning of pregnancy and then monthly."></img></a></p><p class="elsevierStylePara">Figure 1. Laboratory parameters progression over the follow-up period. Follow-up at 3 months after the beginning of pregnancy and then monthly.</p>" "pdfFichero" => "P1-E46-S1860-A10354-EN.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437254" "palabras" => array:1 [ 0 => "Proteinuria" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437256" "palabras" => array:1 [ 0 => "end stage renal disease" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437258" "palabras" => array:1 [ 0 => "Pregnancy" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10354_18030_5954_en_figure1.jpg" "Alto" => 327 "Ancho" => 519 "Tamanyo" => 127973 ] ] "descripcion" => array:1 [ "en" => "Laboratory parameters progression over the follow-up period. 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Kidney Int. 2009 Jun; 75(11):1217-22. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19242506" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000003/v0_201502091603/X2013251410035858/v0_201502091604/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000003/v0_201502091603/X2013251410035858/v0_201502091604/en/P1-E46-S1860-A10354-EN.pdf?idApp=UINPBA000064&text.app=https://www.revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410035858?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 49 | 32 | 81 |
| 2024 September | 56 | 29 | 85 |
| 2024 August | 76 | 56 | 132 |
| 2024 July | 40 | 27 | 67 |
| 2024 June | 90 | 50 | 140 |
| 2024 May | 76 | 48 | 124 |
| 2024 April | 60 | 39 | 99 |
| 2024 March | 65 | 24 | 89 |
| 2024 February | 54 | 29 | 83 |
| 2024 January | 77 | 24 | 101 |
| 2023 December | 77 | 22 | 99 |
| 2023 November | 59 | 34 | 93 |
| 2023 October | 64 | 39 | 103 |
| 2023 September | 72 | 28 | 100 |
| 2023 August | 68 | 29 | 97 |
| 2023 July | 100 | 31 | 131 |
| 2023 June | 126 | 26 | 152 |
| 2023 May | 81 | 29 | 110 |
| 2023 April | 81 | 19 | 100 |
| 2023 March | 110 | 23 | 133 |
| 2023 February | 52 | 16 | 68 |
| 2023 January | 66 | 27 | 93 |
| 2022 December | 59 | 28 | 87 |
| 2022 November | 51 | 39 | 90 |
| 2022 October | 47 | 47 | 94 |
| 2022 September | 46 | 30 | 76 |
| 2022 August | 56 | 45 | 101 |
| 2022 July | 45 | 44 | 89 |
| 2022 June | 58 | 40 | 98 |
| 2022 May | 45 | 38 | 83 |
| 2022 April | 76 | 54 | 130 |
| 2022 March | 52 | 59 | 111 |
| 2022 February | 80 | 52 | 132 |
| 2022 January | 41 | 31 | 72 |
| 2021 December | 59 | 41 | 100 |
| 2021 November | 52 | 28 | 80 |
| 2021 October | 84 | 52 | 136 |
| 2021 September | 35 | 32 | 67 |
| 2021 August | 51 | 36 | 87 |
| 2021 July | 64 | 34 | 98 |
| 2021 June | 60 | 25 | 85 |
| 2021 May | 81 | 32 | 113 |
| 2021 April | 141 | 75 | 216 |
| 2021 March | 83 | 40 | 123 |
| 2021 February | 53 | 15 | 68 |
| 2021 January | 64 | 19 | 83 |
| 2020 December | 49 | 18 | 67 |
| 2020 November | 45 | 16 | 61 |
| 2020 October | 44 | 12 | 56 |
| 2020 September | 46 | 17 | 63 |
| 2020 August | 41 | 11 | 52 |
| 2020 July | 61 | 5 | 66 |
| 2020 June | 81 | 10 | 91 |
| 2020 May | 62 | 16 | 78 |
| 2020 April | 110 | 33 | 143 |
| 2020 March | 69 | 18 | 87 |
| 2020 February | 68 | 17 | 85 |
| 2020 January | 85 | 21 | 106 |
| 2019 December | 101 | 21 | 122 |
| 2019 November | 121 | 21 | 142 |
| 2019 October | 97 | 8 | 105 |
| 2019 September | 154 | 31 | 185 |
| 2019 August | 117 | 26 | 143 |
| 2019 July | 87 | 26 | 113 |
| 2019 June | 72 | 22 | 94 |
| 2019 May | 78 | 25 | 103 |
| 2019 April | 135 | 30 | 165 |
| 2019 March | 76 | 24 | 100 |
| 2019 February | 39 | 16 | 55 |
| 2019 January | 57 | 15 | 72 |
| 2018 December | 125 | 25 | 150 |
| 2018 November | 205 | 11 | 216 |
| 2018 October | 191 | 13 | 204 |
| 2018 September | 153 | 14 | 167 |
| 2018 August | 75 | 10 | 85 |
| 2018 July | 41 | 10 | 51 |
| 2018 June | 42 | 7 | 49 |
| 2018 May | 54 | 9 | 63 |
| 2018 April | 69 | 9 | 78 |
| 2018 March | 52 | 9 | 61 |
| 2018 February | 55 | 5 | 60 |
| 2018 January | 37 | 8 | 45 |
| 2017 December | 42 | 4 | 46 |
| 2017 November | 39 | 6 | 45 |
| 2017 October | 42 | 5 | 47 |
| 2017 September | 37 | 19 | 56 |
| 2017 August | 38 | 12 | 50 |
| 2017 July | 48 | 17 | 65 |
| 2017 June | 33 | 18 | 51 |
| 2017 May | 49 | 20 | 69 |
| 2017 April | 56 | 7 | 63 |
| 2017 March | 22 | 21 | 43 |
| 2017 February | 27 | 9 | 36 |
| 2017 January | 26 | 9 | 35 |
| 2016 December | 69 | 6 | 75 |
| 2016 November | 86 | 6 | 92 |
| 2016 October | 131 | 3 | 134 |
| 2016 September | 146 | 2 | 148 |
| 2016 August | 198 | 4 | 202 |
| 2016 July | 167 | 1 | 168 |
| 2016 June | 136 | 0 | 136 |
| 2016 May | 139 | 0 | 139 |
| 2016 April | 62 | 0 | 62 |
| 2016 March | 90 | 0 | 90 |
| 2016 February | 100 | 0 | 100 |
| 2016 January | 94 | 0 | 94 |
| 2015 December | 104 | 0 | 104 |
| 2015 November | 67 | 0 | 67 |
| 2015 October | 72 | 0 | 72 |
| 2015 September | 70 | 0 | 70 |
| 2015 August | 65 | 0 | 65 |
| 2015 July | 53 | 0 | 53 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 54 | 0 | 54 |
| 2015 April | 6 | 0 | 6 |
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