Pregnancy in chronic kidney disease stage 4: a case series from a referral center

Objective: pregnancy in women with advanced chronic kidney disease (CKD) is associated with a high risk of adverse outcomes for the mother and the fetus. Setting of care is a potential determinant of the results, but data about pregnancy course in different settings are still limited. In this retrospective study, we aimed to analyze the course and outcomes of pregnancy in women with CKD stage 4 followed-up in a referral center in Russia. Materials and methods: thirteen pregnant women with CKD stage 4 were followed in a dedicated unit for pregnant women with kidney diseases. Main data collected: CKD cause, obstetric history, pre-gestational serum creatinine (sCr), week of gestation at the first visit, proteinuria, sCr and blood pressure (BP) at referral and each trimester, type and week of delivery and pregnancy outcome. Physiological kidney response to pregnancy was considered as a persistent decrease of SCr by ≥10 μmol/L from the pre-gestational level. Superimposed PE was diagnosed based on the abrupt increase of blood pressure, proteinuria and/or sCr, together with alteration of the angiogenic-antiangiogenic ratio, whenever available. Pregnancy management included BP control, anemia correction, antiplatelet and anticoagulant therapy, and urinary tract infection treatment. Results: arterial hypertension was present at referral in 6/13 cases, the mean BP decreased by the 3-rd trimester under treatment. Proteinuria increased during pregnancy in all cases, more rapidly in women who subsequently developed preeclampsia. Mean sCr at referral to the center was 184±13.3 μmol/L, urea 9.8±0.6 mmol/l, eGFR 32.9±2.9 ml/min/1.73 m2. Postpartum sCr increased to 243.4±37.8 μmol/L, urea 11.9±0.7 mmol/L, and eGFR dropped to 21.8±1.4 ml/min/1.73 m2. Median term of delivery was 34 weeks of gestation. Superimposed preeclampsia was diagnosed in 6 cases. All newborns were alive and viable. None of the patients needed dialysis during pregnancy or immediately after delivery. Conclusion: a favorable pregnancy outcome, defined as a viable baby without major health issues, is possible in women with CKD stage 4, however prematurity is common, and a decrease in the kidney function is observed in most of the cases.

хроническая болезнь почек, артериальная гипертензия, преэклампсия, беременность, chronic kidney disease, hypertension, preeclampsia, pregnancy outcome

1. Bramham K., Briley A.L., Seed PT. et al. Pregnancy outcome in women with chronic kidney disease: a prospective cohort study. Reprod Sci. 2011. 18:623-630. doi: 10.1177/1933719110395403

2. Shahir A.K., Briggs N., Katsoulis J. et al. An observational outcomes study from 1966-2008, examining pregnancy and neonatal outcomes from dialysed women using data from the ANZDATA Registry. Nephrology. 2013. 18:276-284. doi: 10.1111/nep.12044

3. Kendrick J.S.S., Holmen J., Palit S. et al. Kidney disease and maternal and fetal outcomes in pregnancy. Am J Kidney Dis. 2015. 66:55-59. doi: 10.1053/j.ajkd.2014.11.019

4. Piccoli G.B., Cabiddu G., Attini R. et al. Risk of Adverse Pregnancy Outcomes in Women with CKD. J Am Soc Nephrol. 2015. 26(8):2011-2022. doi: 10.1681/ASN.2014050459

5. He Y., Liu, J., Cai Q. et al. The pregnancy outcomes in patients with stage 3-4 chronic kidney disease and the effects of pregnancy in the long-term kidney function. J Nephrol. 2018. 31:953-960. doi: 10.1007/s40620-018-0509-z

6. Rivera J.C.H., Pérez López M.J., Corzo Bermúdez C.H. et al. Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country. J Clin Med. 2019. 8(4):475. Published 2019 Apr 8. doi:10.3390/jcm8040475

7. Nikolskaya I.G., Prokopenko E.I., Novikova S.V. et al. Complications and outcomes of pregnancy in chronic renal failure. Almanac Clinical Medicine (Russian). 2015. (37):52-69. doi: 10.18786/2072-0505-2015-37-52-69

8. Imbasciati E., Gregorini G., Cabiddu G. et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes. Am J Kidney Dis. 2007. 49:753-762. doi: 10.1053/j.ajkd.2007.03.022

9. Wiles K., Webster P., Seed P.T. et al. The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes. Nephrol Dial Transplant. 2021. 36(11):2008-2017. doi: 10.1093/ndt/gfaa247

10. Regitz-Zagrosek V., Roos-Hesselink J.W., Bauersachs J., et al. ESC Scientific Document Group, 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal. 2018. 39(34):3165-3241. doi: 10.1093/eurheartj/ehy340

11. Maynard S.E., Thadhani R. Pregnancy and the kidney. J Am Soc Nephrol. 2009. 20(1):14-22. doi: 10.1681/ASN.2008050493

12. Hall M. Pregnancy in Women with CKD: A Success Story. Am J Kidney Dis. 2016. 68(4):633-639. doi: 10.1053/j.ajkd.2016.04.022

13. Cabiddu G., Castellino S., Gernone G. et al. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol. 2016. 29(3):277-303. doi: 10.1007/s40620-016-0285-6

14. Park S., Lee S.M., Park J.S. et al. Midterm eGFR and Adverse Pregnancy Outcomes: The Clinical Significance of Gestational Hyperfiltration. Clin J Am Soc Nephrol. 2017. 12(7): 1048-1056. doi: 10.2215/CJN.12101116

15. Gosselink M.E., van Buren M.C., Kooiman J. et al. A National wide Dutch cohort Study shows relatively good pregnancy outcomes after kidney transplantation and finds risk factors for adverse outcomes. Kidney International 2022. 102(4):866-875. doi: 10.1016/j.kint.2022.06.006

16. Alkhunaizi A., Melamed N., Hladunewich M.A. Pregnancy in advanced chronic kidney disease and end-stage renal disease. Curr Opin Nephrol Hypertens. 2015. 24:252-259. doi: 10.1097/MNH.0000000000000119

17. Feng Z., Minard C., Raghavan R. Pregnancy outcomes in advanced kidney disease. Clin Nephrol. 2015. 83(5):272-8. doi: 10.5414/cn108516. PMID: 25899576

18. He Y., Li Z., Chen S. et al. Pregnancy in patients with stage 3-5 CKD: Maternal and fetal outcomes. Pregnancy Hypertension. 2022. 29:86-91. doi:10.1016/j.preghy.2022.06.005

19. Strevens H., Wide-Swensson D., Hansen A. et al. Glomerular endotheliosis in normal pregnancy and pre-eclampsia. BJOG: An International Journal of Obstetrics & Gynaecology. 2003. 110:831-836. doi:10.1111/j.1471-0528.2003.02162.x

20. Demyanova K.A., Kozlovskaya N.L., Korotchaeva Y.V. et al. Analysis of the course and outcomes of pregnancy in patients with advanced stages chronic kidney disease. Terapevticheskii arkhiv. 2021. 93(6):685-692. doi: 10.26442/00403660.2021.06.200867

21. Piccoli G.B., Conijn A., Attini R. et al. Pregnancy in chronic kidney disease: need for a common language. J Nephrol. 2011. 24(3):282-299. doi: 10.5301/JN.2011.797