Glomerular hyperfiltration, altered tubular function, and shifts in electrolyte-fluid balance are among the hallmark renal physiologic changes that characterize a healthy pregnancy. These adjustments ...are not only critical to maternal and fetal well being, but also provide the clinical context for identifying gestational aberrations in renal function and electrolyte composition. Systemic vasodilation characterizes early gestation and produces increments in renal plasma flow and GFR, the latter of which is maintained into the postpartum period. In addition, renal tubular changes allow for the accumulation of nutrients and electrolytes necessary for fetal growth such that wasting of proteins, glucose, and amino acids in urine is limited in pregnancy and total body stores of electrolytes increase throughout gestation. Substantial insight into the mechanisms underlying these complex adjustments can be gleaned from the available animal and human literature, but our understanding in many areas remains incomplete. This article reviews the available literature on renal adaptation to normal pregnancy, including renal function, tubular function, and electrolyte-fluid balance, along with the clinical ramifications of these adjustments, the limitations of the existing literature, and suggestions for future studies.
Pregnancy is uncommon in women with end-stage renal disease (ESRD). Fertility rates are low in women on dialysis, and physicians still frequently counsel women with ESRD against pregnancy. ...Advancements in the delivery of dialysis and obstetric care have led to improved live birth rates in women on dialysis, so pregnancy for young women with ESRD is now more feasible and safer. However, these pregnancies remain high-risk for both maternal and fetal complications, necessitating experienced multidisciplinary care. In this article, we review fertility issues in women with ESRD, discuss pregnancy outcomes in women on dialysis, and provide an approach for management of pregnant women with ESRD.
During pregnancy, CKD increases both maternal and fetal risk. Adverse maternal outcomes include progression of underlying renal dysfunction, worsening of urine protein, and hypertension, whereas ...adverse fetal outcomes include fetal loss, intrauterine growth restriction, and preterm delivery. As such, pregnancy in young women with CKD is anxiety provoking for both the patient and the clinician providing care, and because the heterogeneous group of glomerular diseases often affects young women, this is an area of heightened concern. In this invited review, we discuss pregnancy outcomes in young women with glomerular diseases. We have performed a systematic review in attempt to better understand these outcomes among young women with primary GN, we review the studies of pregnancy outcomes in lupus nephritis, and finally, we provide a potential construct for management. Although it is safe to say that the vast majority of young women with glomerular disease will have a live birth, the counseling that we can provide with respect to individualized risk remains imprecise in primary GN because the existing literature is extremely dated, and all management principles are extrapolated primarily from studies in lupus nephritis and diabetes. As such, the study of pregnancy outcomes and management strategies in these rare diseases requires a renewed interest and a dedicated collaborative effort.
Women’s Reproductive Health for the Nephrologist Burgner, Anna; Hladunewich, Michelle A.
American journal of kidney diseases,
November 2019, 2019-11-00, Letnik:
74, Številka:
5
Journal Article
Recenzirano
Women with chronic kidney disease (CKD) are faced with complex decisions and significant challenges during their reproductive years. Contraceptive choices have a variety of side effects that can ...disproportionately affect women with CKD, limiting choice. CKD itself and the therapies needed to treat severe disease can affect future fertility. When conception is desired, young women with CKD must plan meticulously because an ill-timed pregnancy can result in disease progression or flare and exposure of an unborn child to potentially teratogenic medications. Among women with CKD, pregnancy risks are substantial, with up to 10-fold higher risk for preeclampsia and 6-fold higher risk for preterm delivery. These pregnancy complications associated with inadequate placentation also increase maternal and newborn risks for cardiovascular morbidity and mortality and progression to kidney failure later in life. As such, it is the obligation of every nephrologist caring for women of reproductive age to provide guidance in the choice of methods to prevent unplanned pregnancies, to choose treatments that preserve fertility, and to participate in shared decision making that optimizes pregnancy timing and outcomes. In this perspective, we review the many challenges associated with reproductive counseling in women with CKD.
This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who ...require renal replacement therapy.
Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.
Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.
Contraception and CKD Burgner, Anna; Hladunewich, Michelle A
Clinical journal of the American Society of Nephrology,
04/2020, Letnik:
15, Številka:
4
Journal Article
Pregnancy associated with lupus, especially lupus nephritis, is often fraught with concern for both the mother and fetus. Thus, it is paramount that care begins preconception so that proper planning ...in terms of optimizing the medical regimen, discontinuation of fetotoxic agents, and treatment of active disease can occur. It is well known that active nephritis at the time of conception is associated with poor outcomes. Even with quiescent disease, recent data indicate that being lupus anticoagulant-positive, nonwhite or Hispanic, and using antihypertensive medications were all predictors of worse pregnancy outcomes. Further, prior lupus nephritis also predicts higher rates of preeclampsia and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Differentiating lupus nephritis from preeclampsia often presents as a conundrum, but lupus nephritis can be confirmed by the presence of decreasing complement levels and increasing double-stranded DNA (dsDNA) antibody levels in addition to new onset hypertension and proteinuria. We hope that the more mechanistic approach of measuring angiogenic markers, which are diagnostic for preeclampsia, will be the standard of care in the future. Women with lupus and prior lupus nephritis can have successful pregnancies, but outcomes are dependent on "the art of planning" as well as close communication between the obstetrician, the nephrologist, and the rheumatologist.
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