A systematic review and meta-analysis indicates long-term risk of chronic and end-stage kidney disease after preeclampsia

Abstract

Preeclampsia is a pregnancy-related syndrome of variable severity, classically characterized by acute kidney involvement, with hypertension and/or proteinuria and reduced kidney function. Once considered a self-limited disease healed by delivery, it is now acknowledged that preeclampsia can affect cardiovascular and kidney health in the long term. The entity of risk has not been established and consequently follow-up policies have not been defined. Here we undertook a systematic review to gain better insights into the need for post-preeclampsia followup. Articles published between January 2000 and March 2018 were selected, dealing with at least 20 preeclampsia patients, with follow-up of 4 years or more (MEDLINE, Embase, and Cochrane Library). No quality selection or language restriction was performed. Of the 10,510 titles and abstracts originally considered, 21 papers were selected, providing information on 110,803 cases with and 2,680,929 controls without preeclampsia, with partial overlap between studies on the same databases. Heterogeneity was high, and a random meta-analytic model selected. The increase in risk of end stage renal disease after preeclampsia was significant (meta-analytic risk ratios (95% confidence interval) 6.35 (2.73-14.79)); the risk of albuminuria and chronic kidney disease increased but statistical significance was not reached (4.31 (0.95-19.58) and 2.03 (0.58-7.32), respectively). Translating meta-analytic risk into the number of patients who need follow-up to detect one adverse event, 310 patients with preeclampsia are needed to identify one woman with end stage renal disease or four to identify one woman with albuminuria. Heterogeneity in definitions, insufficient follow-up and incomplete recruitment may account for discrepancies. Thus, preeclampsia significantly increases the risk of end stage renal disease. However, there is lack of sufficient data to show a relationship between preeclampsia, albuminuria and chronic kidney disease, underlining the need for further prospective studies.

Hypertensive disorders of pregnancy and the risk of chronic kidney disease: A Swedish registry-based cohort study

“…It complicates 3%-5% of pregnancies worldwide [2], and affected women are at higher risk of long-term cardiovascular disease (CVD) [3][4][5]. Preeclampsia has also been described as a reversible kidney disease that typically self-resolves within 3 months of delivery [6]. However, there is increasing evidence that some women experience sustained renal dysfunction, and large cohort studies have reported an increased risk of end-stage kidney disease (ESKD) [7][8][9][10].…”

“…Other changes in the renin-angiotensin-aldosterone system, metabolic system, and factors causing endothelial dysfunction may also be involved. Chronic kidney disease (CKD) is much more prevalent than ESKD, and although it may be considered a precursor to ESKD, the evidence for associations between preeclampsia and CKD has been inconsistent to date [6,14]. Cohort studies from Scotland and Denmark have reported increased risk of CKD following preeclampsia [15,16], but these findings have not been replicated elsewhere [17,18].…”

Preeclampsia: A Diagnosis-Nondiagnosis That Is Too Easily Made: The Case of Primary Hyperaldosteronism

“…

After decades in which the major medical textbooks reported with slightly different wordings that preeclampsia (PE) in pregnancy is a transitory kidney disease ultimately cured when the mother delivers, we are finally acknowledging that PE is neither always transitory nor systematically cured and that it may be both the herald of future diseases of the kidney and the cardiovascular system and the epiphenomenon of an underlying disease, as the interesting and well-presented case series published here demonstrates [1][2][3]. While the number of systematic reviews, large-population studies, and long-term registry data are multiplying and most of them conclude with a generic statement that future studies, actions, and programs are needed, few if any changes are taking place in real-life clinical practice [4].The result of this dangerous combination of minimalism (PE is a self-healing disorder), lack of interdisciplinary collaboration (the pragmatic obstetrician holding that "nephrologists make things too complicated," while the cultivated nephrologist retorts that "obstetricians oversimplify"), short-sightedness, and common alibis (no time to see all these women after a PE episode, someone else should do it …) is that women who have already had a stressful and occasionally life-threatening episode of PE lose a precious occasion to receive a timely diagnosis of a potentially curable disease.The series reported here is a clear example of how pregnancy is a valuable but often missed occasion for diagnosis of a potentially serious disease: of the 14 patients described, only 3 were diagnosed as having primary hyperaldosteronism within 1 year from the discovery of hypertension, while in 8 the interval was 5 years or more (up to 12 years).

…”

“…After decades in which the major medical textbooks reported with slightly different wordings that preeclampsia (PE) in pregnancy is a transitory kidney disease ultimately cured when the mother delivers, we are finally acknowledging that PE is neither always transitory nor systematically cured and that it may be both the herald of future diseases of the kidney and the cardiovascular system and the epiphenomenon of an underlying disease, as the interesting and well-presented case series published here demonstrates [1][2][3]. While the number of systematic reviews, large-population studies, and long-term registry data are multiplying and most of them conclude with a generic statement that future studies, actions, and programs are needed, few if any changes are taking place in real-life clinical practice [4].…”

Is preeclampsia a risk for end-stage renal disease?

“…6,7 On the other hand, a study that investigated proteinuria and renal function in former preeclamptic women 10 years after giving birth demonstrated only a high-normal estimated glomerular filtration rate and a slightly higher protein excretion. 8 To better assess the long-term renal risk of preeclampsia, Covella et al 9 performed a systematic review and a metaanalysis by selecting 21 papers, including 11 meta-analyses, published after 2000. Only papers reporting follow-ups of at least 4 years were selected.…”