Pregnancy in women with chronic renal failure

Pregnancy in patients with chronic renal failure (CRF) is associated with serious clinical problems – high rate of preeclampsia, preterm delivery, possibility of unfavorable perinatal outcomes and persistent deterioration of renal function. The aim of the study was assessment of pregnancy course and outcome, influence of pregnancy on renal function in patients with CRF. Thirteen women with stage III chronic kidney disease (CKD) were included to the study. Before pregnancy median GFR was 51 ml/min (min 34,5; max 59). Patients had CRF from 2 to 14 years. For prophylaxis of fetoplacental insufficiency and preeclampsia all patients received gestagens, heparin and dipyridamole since early stages of pregnancy. We observed favorable pregnancy outcome in 12 cases of 13 (92,3%). One newborn died in neonatal period. The incidence of preeclampsia was 76,9%, severe preeclampsia – 15,4%, preterm delivery before 37 weeks of pregnancy, delivery before 34 weeks – 15,4%. Median term of delivery was 37 weeks (min 25; max 38), birthweight – 2680 г (min 670; max 3610). Respiratory distress syndrome appeared in 23,1% newborns. Favorable «nephrological» outcome was observed in 76,9% patients. Acute kidney injury in perinatal period appeared in 23,1% women, who subsequently had persistent CRF reduction (>25%, but <50% from basic level). None of the patients required dialysis treatment during pregnancy and early post delivery. None of women required a continuous renal replacement therapy during 12 months after delivery. Probability of a favorable outcome of pregnancy in women with stage III CKD is high when planning pregnancy, careful surveillance by obstetrician-gynecologist and nephrologist, prophylaxis of preeclampsia with early gestation.

pregnancy, outcomes, chronic kidney disease, chronic renal failure, беременность, исходы, хроническая болезнь почек, хроническая почечная недостаточность

1. Гурьева В.М., Петрухин В.А., Бурумкулова Ф.Ф., Холдина М.А. Планирование беременности и профилактика фетоплацентарной недостаточности у женщин группы высокого риска. Вопросы гинекологии, акушерства и перинатологии // 2012. № 3. С. 77–79.

2. Илизарова Н.А., Кулешов В.М., Маринкин И.О., Бгатова Н.П. Анализ морфоструктурных изменений эндометрия на фоне различных схем предгравидарной подготовки у пациенток с привычным невынашиванием беременности // Вестник Национального медико-хирургического центра им. Н.И. Пирогова. 2009. Т. 4. № 1. С. 100–104.

3. Рогов В.А., Тареева И.Е., Сидорова И.С. и др. Ацетилсалициловая кислота и курантил в профилактике осложнений беременности при гломерулонефрите и гипертонической болезни // Тер. арх. 1993. № 6. С. 65–68.

4. Руководство по нефрологии / Под ред. Р.В. Шрайера, перевод с англ. под ред. Н.А. Мухина. М.: ГЭОТАР-Медиа, 2009. 560 с.

5. Савельева Г.М., Кулаков В.И., Серов В.Н. и др. Современные подходы к диагностике, профилактике и лечению гестоза // Методические указания № 99/80. М., 1999. 28 с.

6. Серов В.Н. Профилактика материнской смертности // Русский медицинский журнал. 2008. № 1. С. 1–5.

7. Стародубов В.И. Вопросы статистического учета и мониторинг младенческой смертности // Материалы I Международного Форума «Пути снижения младенческой смертности – Российский опыт», Москва, 11–13 октября 2011 г.

8. Федорова М.В., Ефимов В.С., Петрухин В.А., Гришин В.Л. Использование ингаляций гепарина в акушерской практике // Вестник Росс. ассоц. акушер.-гинекол. 1996. №1. С. 69–73.

9. Шалина Р.И., Ефимов В.С., Гришин В.Л., Москвина С.П. Коррекция гемокоагуляции как способ предупреждения преэклампсии у беременных // В кн.: “Тромбозы и геморрагии, ДВС-синдром. Проблемы лечения». М., 1997. С. 167–168.

10. Arck P.C., Rücke M., Rose M. et al. Early risk factors for miscarriage: a prospective cohort study in pregnant women // Reprod. Biomed. Online. 2008. Vol. 17 (1). P. 101–113.

11. Badawy A.M., Khiary M., Sherif L.S. et al. Low-molecular weight heparin in patients with recurrent early miscarriages of unknown aetiology // J. Obstet. Gynaecol. 2008. Vol. 3. P. 280–284.

12. Bakker R., Steegers E.A., Hofman A., Jaddoe V.W. Blood pressure in different gestational trimesters, fetal growth, and the risk of adverse birth outcomes: the generation R study // Am. J. Epidemiol. 2011. Vol. 174 (7). P. 797–806.

13. Brenner B. Enoxaparin use in pregnancy: state of the art // Womens Health (Lond Engl). 2007. Vol. 3 (1). P. 9–14.

14. Briner V.A., Berl T., Schrier R.W.: Renal function in pregnancy, In Schrier RW (Ed): Renal and Electrolyte Disorders, 4th edition / Boston, Mass, Little, Brown, 1992. P. 635–680.

15. CLASP Collaborative Group. CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women // Lancet. 1994. Vol. 343. P. 619–627.

16. Cornelis T., Odutayo A., Keunen J., Hladunewich M. The kidney in normal pregnancy and preeclampsia // Semin. Nephrol. 2011. P. 31 (1). P. 4–14.

17. Cunningham F.G., Cox S.M., Harstad T.W. et al. Chronic renal disease and pregnancy outcome // Am. J. Obstet. Gynecol. 1990. Vol. 163. P. 453–459.

18. Davison J. M. Renal hemodynamics and volume homeostasis in pregnancy // Scand. J. Clin. Lab. Invest. Suppl. 1984. Vol. 169. P. 15–24.

19. Davison J.M., Lindheimer M.D. Chronic renal disease // Clin. Obstet. Gynecol. 1984. Vol. 27 (4). P. 891–901.

20. Fiedler K., Würfel W. Effectivity of heparin in assisted reproduction // Eur. J. Med. Res. 2004. Vol. 9 (4). P. 207–214.

21. Fischer M.J., Lehnerz S.D., Hebert J.R., Parikh C.R. Kidney disease is an independent risk factor for adverse fetal and maternal outcomes in pregnancy // Am. J. Kidney Dis. 2004. Vol. 43. P. 415–423.

22. Gris J.C., Chauleur C., Molinari N. et al. Addition of enoxaparin to aspirin for the secondary prevention of placental vascular complications in women with severe pre-eclampsia // The pilot randomised controlled NOH-PE trial. Thromb. Haemost. 2011. Vol. 106 (6). P. 1053–1061.

23. Imbasciati E., Gregorinin G., Cabiddu G. et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes // Am. J. Kidney Dis. 2007. Vol. 49. P. 753–762.

24. Jones D.C., Hayslett J.P. Outcome of pregnancy in women with moderate or severe renal insufficiency // N. Engl. J. Med. 1996. Vol. 335. P. 226–232.

25. Jungers P., Chauveau D., Choukroun G. et al. Pregnancy in women with impaired renal function // Clin. Nephrol. 1997. Vol. 47. P. 281–288.

26. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury // Kidney Int. Suppl. 2012. Vol. 2 (1). P. 1–126.

27. Knight M., Duley L., Henderson-Smart D.J., King J.F. WITHDRAWN: Antiplatelet agents for preventing and treating pre-eclampsia // Cochrane Database Syst Rev. 2007. Vol. 2. CD000492.

28. Koleganova N., Piecha G., Ritz E. et al. Both high and low maternal salt intake in pregnancy alter kidney development in the offspring // Am. J. Physiol. Renal. Physiol. 2011. Vol. 301 (2). F344–354.

29. Levey A.S., Eckardt K.U., Tsukamoto Y. et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO) // Kidney Int. 2005. Vol. 67 (6). P. 2089–2100.

30. Mackenzie R., Walker M., Armson A., Hannah M.E. Progesterone for the prevention of preterm birth among women at increased risk: a systematic review and meta-analysis of randomized controlled trials // Am. J. Obstet.Gynecol. 2006. Vol. 194 (5). P. 1234–1242.

31. Mak A., Cheung M.W., Cheak A.A., Ho R.C. Combination of heparin and aspirin is superior to aspirin alone in enhancing live births in patients with recurrent pregnancy loss and positive anti-phospholipid antibodies: a meta-analysis of randomized controlled trials and meta-regression // Oxford. 2010. Vol. 49 (2). P. 281–288.

32. National Kidney Foundation KD. Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification // Am. J. Kidney Dis. 2002. Vol. 4 (39) [Suppl 1]. S1–S266.

33. Piccoli G.B., Attini R., Vasario E. et al. Pregnancy and chronic kidney disease: a challenge in all CKD stages // Clin. J. Am. Soc. Nephrol. 2010. Vol. 5. P. 844–855.

34. Piccoli G.B., Fassio F., Attini R. et al. Pregnancy in CKD: whom should we follow and why? // Nephrol. Dial. Transplant. 2012. 0: P. 1–8. doi: 10.1093/ndt/gfs302.

35. Poon L.C., Kametas N.A., Maiz N. et al. First-trimester prediction of hypertensive disorders in pregnancy // Hypertension. 2009. Vol. 53 (5). P. 812–818.

36. Roy-Clavel E., Picard S., St-Louis J., Brochu M. Induction of intrauterine growth restriction with a low-sodium diet fed to pregnant rats // Am. J. Obstet. Gynecol. 1999. Vol. 180. P. 608–613.

37. Sathishkumar K., Elkins R., Yallampalli U., Yallampalli C. Protein restriction during pregnancy induces hypertension and impairs endothelium-dependent vascular function in adult female offspring // J. Vasc. Res. 2009. Vol. 46 (3). P. 229–239.

38. Sergio F., Maria Clara D., Gabriella F. et al. Prophylaxis of recurrent preeclampsia: low-molecular-weight heparin plus low-dose aspirin versus low-dose aspirin alone // Hypertens. Pregnancy. 2006. Vol. 25 (2). P. 115–127.

39. Sobel M.L., Kingdom J., Drewlo S. Angiogenic response of placental villi to heparin // Obstet. Gynecol. 2011. Vol. 117 (6). P. 1375–1383.

40. Urban G., Vergani P., Tironi R. et al. Antithrombotic prophylaxis in multiparous women with preeclampsia or intrauterine growth retardation in an antecedent pregnancy // Int. J. Fertil. Womens Med. 2007. Vol. 52 (2–3). P. 59–67.

41. Williams D., Davison J. Chronic kidney disease in pregnancy // B.M.J. 2008. Vol. 336. P. 211–215.

42. Wlodek M.E, Ceranic.V, O'Dowd R. et al. Maternal progesterone treatment rescues the mammary impairment following uteroplacental insufficiency and improves postnatal pup growth in the rat // Reprod. Sci. 2009. Vol. 16 (4). P. 380–390.

43. Woods L.L., Weeks D.A., Rasch R. et al. Programming of adult blood pressure by maternal protein restriction: role of nephrogenesis // Kidney Int. 2004. Vol. 65 (4). P. 1339–1348.

44. Yagel S. Angiogenesis in gestational vascular complications // Thromb. Res. 2011. Vol. 127 (Suppl. 3). S64–S66