•Preeclampsia was the main cause of renal function decline at the end of pregnancy.•Podocyturia was not significantly correlated with other renal function markers.•Preeclampsia was the most common ...obstetric complication after renal transplants.•Albumin/creatinine ratios increased during pregnancy and puerperium.•Elevated albumin/creatinine ratio were associated with prematurity.
We aimed to evaluate laboratory markers in women who got pregnant after renal transplantation.
Cross-sectional prospective study.
Renal function parameters and maternal and fetal data were assessed in renal transplant recipients.
Forty-three women who got pregnant after renal transplantation (mean age, 28.5 years; mean gestational age, 35.6 weeks) were included. Most patients (53.5%) received a renal transplant from a deceased donor. Podocyturia was not significantly correlated with other renal function markers. Mean period from transplantation to pregnancy was approximately 5 years; this period was not associated with obstetric complications or changes in renal markers. A gradual increase was observed in the following parameters during pregnancy and puerperium: serum creatinine levels (P < 0.001), proteinuria (P < 0.001), urinary protein/creatinine ratio (P < 0.001), and albumin/creatinine ratio (P < 0.001). The sensitivity and specificity of protein/creatinine ratio in predicting preeclampsia were high (96.0% and 94.0%, respectively). Elevated serum creatinine levels, urinary albumin/creatinine ratio, and retinol-binding protein levels in the third trimester were associated with prematurity (P < 0.001). Preeclampsia was the main cause of renal function decline at the end of pregnancy (65.0% of cases). Approximately four (9.5%) pregnant women presented with premature rupture of membranes and 18 (42.0%) with a urinary tract infection.
Proteinuria, urinary protein/creatinine ratio, and retinol-binding protein levels were elevated in patients with preeclampsia. Using these markers to assess renal function during pregnancy may be clinically useful for detecting and monitoring renal injury in renal transplant recipients.
OBJETIVO: Avaliar a presença de podocitúria em gestantes hipertensas crônicas no terceiro trimestre da gestação e a associação com doença renal.MÉTODOS: Estudo observacional descritivo em uma amostra ...de conveniência de 38 gestantes hipertensas crônicas. Os podócitos foram marcados com técnica de imunofluorescência indireta com antipodocina e diamidino-fenilindol (DAPI). A contagem foi feita a partir de 30 campos analisados de forma aleatória, corrigida pela creatinina urinária (podócitos/mg de creatinina). Foram assumidos dois grupos: grupo GN (função glomerular normal), com até 100 podócitos, e grupo GP (provável glomerulopatia), com mais de 100 podócitos. A dosagem de creatinina foi realizada com uso da técnica do picrato alcalino. As variáveis de análise foram o índice de massa corpórea, a idade gestacional na coleta, a pressão arterial sistólica e a pressão arterial diastólica no momento da coleta. Para a análise dos dados, foi utilizado o programa SPSS - versão 16.0. (IBM - USA). Nas análises estatísticas, foi utilizado o teste do χ2, sendo consideradas diferenças significantes valores de p<0,05.RESULTADOS: A contagem de podócitos no grupo GN teve mediana de 20,3 (0,0 a 98,1), e no grupo GP, de 176,9 (109,1 a 490,6). A média do índice de massa corpórea foi 30,2 kg/m2 (DP=5,6), a média da idade gestacional foi de 35,1 semanas (DP=2,5), a mediana da pressão arterial sistólica foi de 130,0 mmHg (100,0-160,0) e a mediana da pressão arterial diastólica de 80,0 mmHg (60,0-110,0). Não houve correlação significativa entre podocitúria e índice de massa corpórea (p=0,305), idade gestacional na coleta (p=0,392), pressão arterial sistólica (p=0,540) e pressão arterial diastólica (p=0,540).CONCLUSÕES: Não foi identificado um padrão de podocitúria compatível com a presença de glomerulopatia ativa, ainda que algumas das gestantes (15,8%) tenham exibido perda podocitária expressiva. Consideramos ser prematuro recomendar para a prática clínica rotineira a incorporação da pesquisa de podocitúria ao longo do pré-natal de gestantes hipertensas crônicas.
Accurate fetal weight estimation is important for labor and delivery management. So far, there has not been any conclusive evidence to indicate that any technique for fetal weight estimation is ...superior to any other. Clinical formulas for fetal weight estimation are easy to use but have not been extensively studied in the literature. This study aimed to evaluate the accuracy of clinical formulas for fetal weight estimation compared to maternal and ultrasound estimates.
Prospective study involving 100 full-term, cephalic, singleton pregnancies delivered within three days of fetal weight estimation. The setting was a tertiary public teaching hospital in São Paulo, Brazil.
Upon admission, the mother's opinion about fetal weight was recorded. Symphyseal-fundal height and abdominal girth were measured and two formulas were used to calculate fetal weight. An ultrasound scan was then performed by a specialist to estimate fetal weight. The four estimates were compared with the birth weight. The accuracy of the estimates was assessed by calculating the percentage that was within 10% of actual birth weight for each method. The chi-squared test was used for comparisons and p < 0.05 was considered significant.
The birth weight was correctly estimated (+/- 10%) in 59%, 57%, 61%, and 65% of the cases using the mother's estimate, two clinical formulas, and ultrasound estimate, respectively. The accuracy of the four methods did not differ significantly.
Clinical formulas for fetal weight prediction are as accurate as maternal and ultrasound estimates.
Introduction Thrombotic microangiopathy (TMA) represents a spectrum of disorders characterized by thrombosis that affect small arterial vessels. Pregnancy is a potential trigger to acute episodes of ...TMA, which in turn, although rare, are associated with high maternal and perinatal morbidity and mortality. In renal transplant (RT) setting, fertility is increased by restoration of renal function, meanwhile RT patients are more susceptible to gestational complications, such as TMA syndromes. Objectives The aim of this study was to report our experience with RT recipients who developed TMA in allograft during pregnancy. Methods We describe four cases of pregnant RT recipients with TMA diagnosed by allograft biopsy, due to acute allograft dysfunction, at Hospital do Rim between 2011 and 2015. Their clinical and laboratory data were collected and are highlighted here. Results At conception, the average age was 21 ± 4 years. Their obstetric history revealed previous abortions in two patients and one previous uncomplicated pregnancy in another patient. All patients had chronic hypertension before conception and one patient also had preexisting proteinuria greater than 0.5 g. At the time of the confirmation of pregnancy, 75% of the patients were being maintained on immunosuppressive therapy with prednisone, tacrolimus and azathioprine, while one patient was receiving prednisone, tacrolimus and everolimus. The mean interval time of RT to pregnancy was 25 (9–45) months and the average baseline creatinine was 1.1 (0.9–1.4). The TMA diagnosis was established in the 14th week of gestation on average, and it was associated with thrombocytopenia and microangiopathic hemolytic anemia in only one patient. Moreover, concomitant acute cellular rejection (AR) occurred in one patient, and superimposed urinary tract infection in another. Except for the patient who had AR, in all cases the calcineurin inhibitor was withdrawn. Three patients developed preeclampsia with HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome. The mean gestational term at delivery was 23 ± 2 weeks and these resulted in two abortions and two stillbirths. Over a 6 month follow-up period post pregnancy, there was one case of graft loss and all patients had increased proteinuria and creatinine levels – median creatinine = 4.3 (1.5–11); median proteinuria = 1.1 (0.6–1.9). Conclusions Since HELLP syndrome was very prevalent in these cases we suggest that the TMA diagnosis demands careful surveillance for gestational hypertension complications. Apart from the poor pregnancy outcomes, TMA in pregnant RT patients is associated with deterioration of graft function.
Thrombotic microangiopathy (TMA) represents a spectrum of disorders characterized by thrombosis that affect small arterial vessels. Pregnancy is a potential trigger to acute episodes of TMA, which in ...turn, although rare, are associated with high maternal and perinatal morbidity and mortality. In renal transplant (RT) setting, fertility is increased by restoration of renal function, meanwhile RT patients are more susceptible to gestational complications, such as TMA syndromes.
The aim of this study was to report our experience with RT recipients who developed TMA in allograft during pregnancy.
We describe four cases of pregnant RT recipients with TMA diagnosed by allograft biopsy, due to acute allograft dysfunction, at Hospital do Rim between 2011 and 2015. Their clinical and laboratory data were collected and are highlighted here.
At conception, the average age was 21±4years. Their obstetric history revealed previous abortions in two patients and one previous uncomplicated pregnancy in another patient. All patients had chronic hypertension before conception and one patient also had preexisting proteinuria greater than 0.5g. At the time of the confirmation of pregnancy, 75% of the patients were being maintained on immunosuppressive therapy with prednisone, tacrolimus and azathioprine, while one patient was receiving prednisone, tacrolimus and everolimus. The mean interval time of RT to pregnancy was 25 (9–45) months and the average baseline creatinine was 1.1 (0.9–1.4). The TMA diagnosis was established in the 14th week of gestation on average, and it was associated with thrombocytopenia and microangiopathic hemolytic anemia in only one patient. Moreover, concomitant acute cellular rejection (AR) occurred in one patient, and superimposed urinary tract infection in another. Except for the patient who had AR, in all cases the calcineurin inhibitor was withdrawn. Three patients developed preeclampsia with HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome. The mean gestational term at delivery was 23±2weeks and these resulted in two abortions and two stillbirths. Over a 6 month follow-up period post pregnancy, there was one case of graft loss and all patients had increased proteinuria and creatinine levels – median creatinine=4.3 (1.5–11); median proteinuria=1.1 (0.6–1.9).
Since HELLP syndrome was very prevalent in these cases we suggest that the TMA diagnosis demands careful surveillance for gestational hypertension complications. Apart from the poor pregnancy outcomes, TMA in pregnant RT patients is associated with deterioration of graft function.
Background Women regain fertility a few time after renal transplantation. However, viability of pregnancy and maternal complications are still unclear. Methods Retrospective study of pregnancies in ...kidney transplanted patients between 2004 and 2014, followed up 12 months after delivery. Each pregnancy was considered an event. Results There were 53 pregnancies in 36 patients. Mean age was 28 ± 5 years. Pregnancy occurred 4.4 ± 3.0 years post-transplant. Immunosuppression before conception was tacrolimus, azathioprine, and prednisone in 74% of the cases. There were 15% miscarriages in the 1st trimester and 8% in 2nd trimester. In 41% of the cases, it was necessary to induce labor. From all births, 22% were premature and 17% very premature. There were 5% stillbirths and 5% of neonatal deaths. De novo proteinuria occurred in 60%, urinary tract infection in 23%, preeclampsia in 11%, acute rejection in 6%, and graft loss in 2% of the cases. It was observed a significant increase in creatinine at preconception comparing to 3rd trimester and follow-up (1.17 vs. 1.46 vs. 1.59 mg/dL, p < 0.001). Conclusion Although the sample is limited, the number of miscarriages was higher than in the general population, with high rates of maternal complications. Sustained increase of creatinine suggests increased risk of graft loss in long-term.
Introduction Preeclampsia (PE) and cardiovascular disease (CVD) have similar pathophysiological mechanisms and they also share some risk factors. The relationship between hypertensive disorders in ...pregnancy and CVD has not been totally elucidated; perhaps the metabolic stress and vascular injury may contribute to increase this future risk in such women. Objectives Investigate correlation between hypertensive disorders in pregnancy and incidence of postpartum CVD and metabolic syndrome. Methods Case-control study with a total of 65 women (45 normal pregnancy and 20 gestational hypertension). These volunteer patients were submitted to clinical, laboratorial and nutritional evaluation (bioimpedance BIODYNAMICS 310e, USA). The risk scores were estimated by using Findrisc Diabetes Risk Calculator (FDRC) and Framingham Risk Score ATP III (FRS-ATPIII); diagnosis of metabolic syndrome was based on the International Diabetes Federation (IDF) worldwide definition. Results Mean age of control group (CG) was 47.5 years and of gestational hypertension group (HG) was 43.8 years. The mean period postpartum that those patients were evaluated was 12.4 years in HG and 18.0 years in CG. Half of the HG had preeclampsia. Chronic hypertension (CH) was observed in 70% of HG and 24% of CG ( p ⩽ 0.05). FDRC indicated high risk of diabetes over 10 years in 45% of HG and 21% of CG. Metabolic syndrome was present in 75% of HG and 26.6% in CG ( p ⩽ 0.05). The mean body mass index (BMI) was 31.5 kg/m2 (obese) in HG and 26.5 kg/m2 (overweight) in CG. The body fat percentage detected by bioimpedance was similar, 38.5% in HG and 35.8% in CG. The FRS-ATPIII indicated low risk of CVD over 10 years in both groups. Conclusions The incidence of CH and metabolic syndrome appears to be increased in women who had hypertensive disorders in pregnancy, especially PE. A higher risk of developing diabetes over 10 years was also found in HG. The investigation of the history of hypertension during pregnancy may help preventing and early diagnosing those comorbidities. Fapesp n° 2014/00213-7
Introduction Glomerular filtration rate (GFR) increases during pregnancy and some incipient nephropathies may appear after this period, especially when gestational hypertension (GH) is present. ...Objectives Renal evaluation in women over 10 years after pregnancy. Methods Total of 30 volunteer patients whose last childbirth was 10–20 years ago. Renal parameters assessed were: urinary excretion of retinol-binding protein (RBP), urine protein/creatinine ratio (PCR), Urine albumin/creatinine ratio (ACR), serum creatinine, serum C cystatin, vitamin D (25OHD), serum uric acid, vascular endothelial growth factor (VEGF), estimated GFR (eGFR) based on Modification of Diet in Renal Disease (MDRD) Study and the Chronic Kidney Disease Epidemiology Collaboration equation – CKD-EPI Creatinine, 2009 (CKD-EPI crea), CKD-EPI Cystatin C, 2012 (CKD-EPI cys) and CKD-EPI Creatinine-Cystatin C, 2012 (CKD-EPI crea-cys) equations. Results The average age was 45.5 years old, 56.6% were afro descendant, and mean time after last labor was 13.7 years. Approximately 6.6% had type 2 diabetes and 30.3% had chronic hypertension (CH) after pregnancy (among them 90% had GH). Mean body mass index (BMI) was 29.1 kg/m2 (overweight), although all patients with CAH were obese. Mean value of cystatin C was 1.45 mg/L (elevated in 20%), RBP 0.30 mg/L (high level in only one case), PCR 0.02 g/g, ACR 6.91 mg/g creatinine (high level in only one case), 25OHD 24.34 ng/mL (deficiency in 33.3%), serum uric acid 4.50 mg/dL (high level in only one case), serum creatinine 0.73 mg/dL (normal level in all cases), VEGF 312.04 pg/mL (high level in two cases). Mean clearance of creatinine using MDRD was 93.5 mL/min/1.73 m2 , CKD-EPI crea 101.7 mL/min/1.73 m2 , CKD-EPI cys 49.0 mL/min/1.73 m2 and CKD-EPI crea-cys 68.3 mL/min/1.73 m2 (about 30% less when compared with the equations without cystatin C, then 26.6% had eGFR < 60 mL/min/1.73 m2 ). None of the patients had ever been assisted by a nephrologist. Conclusions Obesity, CH, 25OHD deficiency, high levels of serum cystatin C and low eGFR may appear years after pregnancy, especially if GH was present. Women who had GH should have long-term follow up with nephrologist to have a more complete and regular renal evaluation. The eGFR by combined creatinine-cystatin C equation seems to be better than other formulas and it could be useful to detect early chronic kidney disease. Fapesp n° 2014/00213-7
Introduction End stage renal disease usually disrupts normal gonadal function and leads to infertility. After successful renal transplantation, fertility improves within months and pregnancy occurs ...in approximately 12% of childbearing age women. Progressive proteinuria and glomerulosclerosis characterize chronic allograft nephropathy. Injury of parietal epithelial cells in glomeruli, the podocytes, is the initiating cause of many renal diseases, leading to proteinuria with possible progression to glomerulosclerosis. Podocytes must completely cover the filtration surface area with foot processes to maintain the glomerular filtration barrier. Failure to achieve this task due to reduced podocyte number, size, or function, or increased glomerular volume (quantitated by “podometric” methodology), results in progressive glomerular dysfunction, causing proteinuria and glomerulosclerosis and ultimately leading to end-stage kidney disease. Assessment of podocyturia and its correlation with other renal parameters could help with the diagnosis and definition of prognosis of the glomerulopathies, thus contributing to risk reduction. As during gestation there is a physiological increase in the glomerular filtration rate and reduction of serum creatinine, even mild elevations of the later can indicate renal function deficit. Objective To evaluate podocyturia and other renal parameters as functional markers in pregnant women. Methods 50 pregnant women with kidney grafts had their urine samples evaluated by indirect immunofluorescence for detection of podocyturia, as well as for dosages of albuminuria and retinol binding protein (urRBP). Results The mean age of the women was 28 years; 17 did not exhibit urinary podocytes and 22 had podocyturia in the 3rd trimester. Serum creatinine levels in the 3rd trimester and post childbirth were both increased compared to the 1st and 2nd trimesters ( p < 0.001). Proteinuria levels were higher when compared to other moments ( p < 0.001); 25 women had microalbuminuria and 30 macroalbuminuria; 35 had elevated urRBP. 35 pregnant women developed pre-eclampsia and high rate of pre-term delivery (50%). Conclusion Levels of urinary podocyte, blood pressure and proteinuria were associated with worsening of kidney function during pregnancy. The proteinuria level in the 3rd trimester was higher when compared to the 1st and 2nd trimesters. There was a significantly greater excretion ( P < 0,001) of ur RBP in the 3rd trimester. We observed that urinary podocyte excretion occurs in pregnant women with kidney transplant almost synchronously with higher systolic and diastolic blood pressure and higher mean levels of proteinuria. The detection of podocyturia in these women could be useful for early diagnosis and follow-up of glomerular injury, and eventually of preeclampsia. It may also be associated to its severity or activity, although additional studies are necessary to confirm these aspects. GRANT FAPESP 20140213-7.
Introduction Assessment of proteinuria is essential to diagnose preeclampsia; it can be detected in spot urine sample or 24-hour urine collection. It has been shown that urine protein to creatinine ...(P/C) ratio seems to be highly predictive for detection of proteinuria in preeclampsia (PE). Objectives Evaluation of P/C ratio in normal pregnancy, and pregnant women with chronic hypertension (CH) and with PE. Methods P/C ratio was measured in 24 normal pregnant women, 14 with PE and 97 with CH. Proteinuria was detected by automated pyrogallol method and creatininuria by alkaline picrate method. Results Mean age of control group was 26 years, of PE group, 26 years and of CH group 34 years. P/C ratio was undetected in the control group, it was elevated in 5.2% of the CH group and in 100% of the PE group, also confirmed with 24-hour urine collection. Serum creatinine was elevated in 19.6% of the CH group and 42.8% of the PE group. Conclusions P/C ratio may be a good predictor of PE and it could be used as an alternative test to detect proteinuria in pregnant women, because it is faster and it is not influenced by serum creatinine concentration. Proteinuria should be evaluated during the prenatal care of CH women allowing early detection of incipient nephropathy. Fapesp n° 2014/00213-7. Renal evaluation in preeclampsia group.
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