Study note
Obstetrics & GynecologyHypertensive Disorders in Pregnancy

Renal disease in pregnancy: risks, management and transplant planning

THE CONTEXT
Renal disease affects pregnancy outcomes, and pregnancy can worsen renal disease. The severity of renal impairment and superimposed pre-eclampsia influence prognosis.

Effects on pregnancy

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Pregnancy outcome depends on the degree of hypertension, proteinuria and serum creatinine elevation.
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Fetal risks include miscarriage, preterm labor, growth restriction and intrauterine fetal death. Improved pregnancy surveillance and neonatal care have improved outcomes.
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Superimposed pre-eclampsia worsens the course; perinatal loss may reach 40–60%.
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The passage describes a healthy newborn outcome in stage I chronic kidney disease with creatinine below 1.4 mg/dL, and reports a live birth rate of 92–93% in moderate to severe chronic kidney disease.

Effects on renal disease

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The risk of end-stage renal failure is reported as 5% with mild renal impairment; renal failure may reach 10% with moderate or severe impairment.
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Superimposed pre-eclampsia worsens renal prognosis.
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Membranoproliferative glomerulonephritis, focal glomerulosclerosis and IgA immunonephropathy have a poorer prognosis than primary glomerulonephritis.
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Persistent or severe blood pressure elevation causes deterioration of renal function.

Counseling and antenatal management

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Women with severely compromised renal function should be discouraged from becoming pregnant because of the high risk of end-stage renal failure.
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Assess renal function periodically. A 24-hour urine collection is used to assess creatinine clearance and total protein excretion.
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Start antihypertensive therapy early to preserve renal function; listed agents include nifedipine, hydralazine, clonidine and beta blockers.
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Diuretics may be used for massive edema. Regular hemodialysis may improve pregnancy outcomes in moderate renal compromise.
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Avoid sudden volume shifts and hypotension.
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Anemia due to chronic renal insufficiency may be treated with recombinant erythropoietin.

Conditions for pregnancy planning after renal transplantation

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Plasma creatinine should be below 1.5 mg/dL, with controlled hypertension and absent or minimal proteinuria.
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The woman should be receiving maintenance immunosuppression and have no evidence of graft rejection.
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