Approach to pregnancy in patient with chronic kidney disease

Jai Prakash Ojha; Vijay Pratap Singh

doi:10.4103/jrnm.jrnm_19_21

MINI REVIEW

Year : 2021 | Volume : 7 | Issue : 2 | Page : 51-54

Approach to pregnancy in patient with chronic kidney disease

Jai Prakash Ojha, Vijay Pratap Singh
Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission	01-Feb-2021
Date of Decision	31-Dec-2021
Date of Acceptance	12-Jan-2022
Date of Web Publication	25-Feb-2022

Correspondence Address:
Dr. Jai Prakash Ojha
Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_19_21

Abstract

A close relationship exists between kidney function and a successful pregnancy outcome. Renal disease can affect the outcome of pregnancy, pregnancy can affect the course of preexisting renal disease, and pregnancy itself can cause acute renal impairment. This article will focus on outcomes of pregnancy in patients with CKD and also pregnancy outcome in patients with ESRD on chronic maintenance dialysis.

Keywords: Albuminuria, blood pressure, chronic kidney disease, pregnancy, renal function

How to cite this article:
Ojha JP, Singh VP. Approach to pregnancy in patient with chronic kidney disease. J Renal Nutr Metab 2021;7:51-4

How to cite this URL:
Ojha JP, Singh VP. Approach to pregnancy in patient with chronic kidney disease. J Renal Nutr Metab [serial online] 2021 [cited 2023 May 28];7:51-4. Available from: http://www.jrnm.in/text.asp?2021/7/2/51/338550

Introduction

Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for >3 months (kidney disease improving global outcomes 2012):^[1]

Criteria for CKD (either of the following present for >3 months), (1) markers of kidney damage (one or more) (albuminuria [albumin excretion rate >30 mg/24 h; albumin to creatinine ratio >30 mg/g [>3 mg/mmol]), Urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, Abnormalities detected by histology, structural abnormalities detected by imaging, history of kidney transplantation]. (2) Decreased glomerular filtration rate (GFR) <60 ml/min/1.73 m² (GFR categories G3a–G5).

A close relationship exists between kidney function and a successful pregnancy outcome. Renal disease can affect the outcome of pregnancy, pregnancy can affect the course of preexisting renal disease, and pregnancy itself can cause acute renal impairment. Women with renal disease who conceive and continue the pregnancy are at risk of adverse maternal and fetal outcomes. Although advances in antenatal and neonatal care continue to improve outcome, the risks remain proportionate to the degree of renal insufficiency. The reproductive hormonal milieu in women with end-stage renal disease (ESRD) remains an enigma. Although CKD is associated with infertility. However, the pregnancy rate in women with renal disease, including end-stage renal failure, is increasing. The reported frequency of conception in women of child-bearing age on dialysis ranges from 0.3% to 1.5%. Although there is still a high rate of fetal loss, improved management of these high-risk pregnancies seems to have improved outcomes. The apparent improvement in outcomes may be attributed to the more aggressive management of pregnant women on dialysis.^[2]

Kidney Disease in Pregnancy

This article will focus on outcomes of pregnancy in patients with CKD and also pregnancy outcome in patients with ESRD on chronic maintenance dialysis. Further, pregnancy may adversely affect the course of CKD, usually in the form of faster progression to ESRD. However, acute kidney injury in pregnancy will not be discussed in this review.

Pregnancy in Known in Patients with Pre-existing Kidney Disease

The successful outcome of pregnancy depends on the degree of renal failure rather than the specific underlying disorder. Patients are thus divided into following three categories:

Mild renal insufficiency if creatinine is <1.5 mg/dl
Moderate renal insufficiency if creatinine is 1.5–3.0 mg/dl
Severe renal impairment when creatinine is >3.0 mg/dl.

An elevated plasma creatinine concentration (>1.5 mg/dl) and hypertension are the major risk factors for permanent exacerbation of underlying renal disease.^[3] Pregnancy is associated with a permanent deterioration of renal function in up to 10% of women with normal or mild renal dysfunction. Others may experience a transient, but reversible, decline in their renal function. On the other hand, women with moderate to severe disease may experience a modest decline in the first half of pregnancy. However, in the latter half of pregnancy, the renal function may increase to above the initial baseline in up to 40% of patients. Studies suggest that one-third of patients experience irreversible decline.^[4] The risk of acceleration of renal disease is greatest in patients with baseline creatinine >2 mg/dl. Thus, women with moderate to severe disease should be counselled against pregnancy as this worsens renal outcomes and may be irreversible. The likelihood of conception and carrying a fetus to term is rare in women with creatinine >3 mg/dl. These women usually have amenorrhoea or anovulatory menstrual cycles. In summary, in women with renal disease who do conceive, the blood pressure should be well controlled as it is an important determinant of outcome. The women of CKD with serum creatinine of >3 mg% are advised against pregnancy.

Effect of Chronic Kidney Disease on Pregnancy

The pregnancy in patients with preexisting CKD is associated with adverse maternal and fetal outcomes. The rate of live births is above 90% in women with normal renal function and lower in those with mild disease, as long as the blood pressure is well controlled. However, pregnancy in the setting of CKD is associated with some severe maternal and fetal risks.

CKD is associated with higher rates of adverse maternal outcomes. These patients are more likely to develop gestational hypertension, pre-eclampsia, and eclampsia. Maternal mortality is higher in women in CKD although this difference was not statistically significant.^[5] Preeclampsia may be more difficult to diagnose in patients with CKD who have preexisting hypertension and proteinuria. Features of preeclampsia in these patients may include worsening hypertension and proteinuria, in association with decreasing platelets and increasing liver enzymes, i.e., development of Hemolysis, elevated liver enzymes and low platelet count syndrome. In women with CKD, preeclampsia is more likely to develop in the second trimester rather than in the third trimester. Fetal outcomes are worse in women with CKD. The rate of premature births, intrauterine growth restriction, small for gestational age, and stillbirths are higher. Fetal survival is lower if hypertension is poorly controlled.^[2]

Drug usage

In addition to the effect of kidney disease on pregnancy, the possible effects of drugs used in kidney disease on the fetus need to be considered. Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and some immunosuppressive drugs should be discontinued as soon as pregnancy is diagnosed. Women of child-bearing age who wishes to become pregnant should be warned of the potential adverse effects of these drugs on the developing fetus.

Approach for a Successful Pregnancy in a Patient with Chronic Kidney Disease

Patients with renal disease should be managed jointly by a nephrologist and an obstetrician familiar with the effects of renal disease on pregnancy.

There is certain specific recommendation regarding timing of conception in patients with diabetic nephropathy, lupus nephropathy, and renal transplant recipients [Table 1].

Table 1: Recommended timing of conception for women with chronic kidney disease^[6]

Click here to view

For women who are planning family, following criteria should be used for referring patients for prepregnancy counselling:^[6]

Women with CKD stage 1–2 and adverse risk factors
Significant proteinuria
Hypertension
Systemic diseases such as lupus or vasculitis or diabetes mellitus
Previous adverse obstetric history.
Women with CKD stage 3–5 including women on dialysis
Women with renal transplants
Women with a family history of hereditary renal disease.

The obstetric managemnt of pregnanct CKD patients should include:^[7]

Increased frequency of antenatal visits – fortnightly till 28-weeks; weekly thereafter

Early detection and treatment of asymptomatic bacteriuria
Serial monitoring (1–2 weekly) of maternal renal function
Close monitoring for the development of preeclampsia. Low dose aspirin from the first trimester
Fetal surveillance with ultrasound to assess fetal growth, including umbilical artery Dopplers and liquor volume
Aggressive treatment of maternal hypertension
Preterm intervention in the presence of deteriorating renal function, severe preeclampsia, fetal growth restriction, or fetal distress
High risk of preterm labor – use MgSO4 cautiously (prevent respiratory depression, toxicity)
Debate over elective early delivery at 34–34 weeks.

The Pregnancy in Patients on Chronic Dialysis

ESRD requiring dialysis is associated with a marked decline in fertility. However, conception on dialysis is unusual but not impossible. Hence adequate contraception remains important in women of childbearing age who do not wish to become pregnant while on dialysis. A 1994 survey of 206 US dialysis unit reported that 1.5% of 1281 women of childbearing age become pregnant over a 2-years period on maintenance hemodialysis. Pregnancy was reported in 2% of 6230 women of childbearing age over a 4-years period on dialysis in 1998 survey of 930 dialysis unit. Thus pregnancy does occur in up to 1% of patients, usually in the first few years after starting dialysis.^[8] In general, pregnancy is contraindicated whilst a patient is on dialysis. However, a review of new evidence suggests that we may have to rethink this approach.^[9]

The fetal outcome is poor, mostly due to the high rate of spontaneous abortions and prematurity. 23%–55% of pregnancies result in surviving infants. The incidence of very low birth weight, small for gestational age and growth-restricted infants is high. Worsening hypertension, which occurs in up to 80% of pregnant women on dialysis, is a major concern.^[10] The diagnosis of pregnancy in these women is also difficult as many have irregular menstruation, and beta-human chorionic gonadotropin levels are usually elevated in patients receiving dialysis. Thus, if pregnancy is suspected, an ultrasound is recommended to aid in the diagnosis.^[8]

Pregnant patients on dialysis require close monitoring. An increased frequency of dialysis may improve mortality and morbidity. Aggressive daily dialysis may be indicated. The major components of the dialysis regimen are:^[11]

More intensive dialysis to achieve urea <45 mg/dl. This may be achieved by more frequent dialysis. This may help avoid polyhydramnios, control hypertension, increase birth weight and gestational age, and improve the mother's nutritional status
Pregnant women require higher doses of erythropoietin as physiological changes of pregnancy may lead to worsening anemia. Erythropoietin should be used with caution as it may worsen hypertension
Metabolic acidosis and hypocalcemia should be corrected
The uterus and fetus should be monitored during hemodialysis. Every attempt should be made to avoid dialysis-induced hypotension. The use of heparin should be minimized to decrease the risk of bleeding
If the patient is on peritoneal dialysis, the volume of the dialysate should be decreased and the frequency of dialysis increased
The patient's blood pressure should be controlled and anemia treated promptly.

Pregnancy in Renal Transplant Recipients

Pregnancy occurs in up to 12% of female patients of childbearing age post transplantation. More than 90% of pregnancies postrenal transplantation is successful. In the correct setting, pregnancy can be planned. Factors such as uncontrolled hypertension, worsening proteinuria, and poor prepregnancy renal function are prognostic indicators of deteriorating renal function. The renal graft is not adversely affected by pregnancy in patients on prednisone or azathioprine and creatinine level < 1.4 mg/dl. However, corticosteroid use impairs glucose control, increases blood pressure, increases the incidence of infections and may cause ectopic pregnancies and uterine rupture. Fetal complications include increased incidence of preterm deliveries, intrauterine fetal growth restriction, congenital anomalies, and decreased platelet counts.^[12],[13]

Conventionally, it has been recommended that women wait approximately 2 years after transplant before attempting conception. However, many women who have undergone renal transplantation are of advanced maternal age, hence delaying pregnancy may lead to age-related decreases in fertility. The American Society of Transplantation currently suggests that for women on stable, low doses of immunosuppressive agents, with normal renal function, and with no prior rejection episodes, conception could be safely considered as early as 1-year posttransplant.^[14]

Pregnancy Outcome in Kidney Donors

Recent study revealed that gestational hypertension or preeclampsia was more common among living kidney donor than among nondonor (occurring in 15 of 131 pregnancy [11%] vs. 38 of 788 pregnancies [5%]). However, most women had uncomplicated pregnancies after donation.^[15]

Conclusion

Kidney disease in pregnancy poses a complex problem. One needs to take into consideration the effects of the pregnancy on renal disease, the effects of renal disease on pregnancy, as well as the effects of the drugs that are used to manage kidney disease. Thus, a multidisciplinary approach is required when managing the pregnant patient with renal disease. The team should consist of an obstetrician familiar with the effects of renal disease on pregnancy, a nephrologist familiar with the effects of pregnancy on renal disease, nutritionists, nurses, and neonatologists. Prepregnancy counseling, close antenatal monitoring, and skilled obstetric management are critical to a successful pregnancy outcome in these patients. A planned pregnancy with an informed, motivated patient presents the best hope of a good maternal and neonatal outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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