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.
Management of the pregnant woman with chronic kidney disease is difficult for both nephrologists and obstetricians. Prepregnancy counselling with respect to risk stratification, optimization of ...maternal health prior to pregnancy, as well as management of the many potential pregnancy-associated complications in this complex patient population remains challenging due to the paucity of large, well-designed clinical studies. Furthermore, the heterogeneity of disease and the relative infrequency of pregnancy, particularly in more advanced stages of chronic kidney disease, leaves many clinicians feeling ill prepared to manage these pregnancies. As such, counselling is imprecise and management varies substantially across centers. All pregnancies in women with chronic kidney disease can benefit from a collaborative multidisciplinary approach with a team that consists of nephrologists experienced in the management of kidney disease in pregnancy, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists. Further access to skilled neonatologists and neonatal intensive care unit support is essential given the risks for preterm delivery in this patient population. The goal of this paper is to highlight some of the data that currently exist in the literature, provide management strategies for the practicing nephrologist at all stages of chronic kidney disease, and explore some of the knowledge gaps where future multinational collaborative research efforts should concentrate to improve pregnancy outcomes in women with kidney disease across the globe.
Dr Susan Hou began her illustrious nephrology career at a time when pregnancy in women with chronic kidney disease (CKD) was hazardous and actively discouraged. Her pioneering research in women’s ...health provided much of the early outcome data that shaped our current understanding of CKD and pregnancy. Although many uncertainties regarding optimal management of this vulnerable patient group remain, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists have been inspired by Dr Hou’s lifetime of work and are grateful for her generous collaborations. In this In Practice Review, we honor her legacy by providing an update of current literature and clinical management guidance in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a pregnancy.
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