A Systematic Review on Materno-Foetal Outcomes in Pregnant Women with IgA Nephropathy: A Case of “Late-Maternal” Preeclampsia?

Abstract

Background: IgA nephropathy is the most common primary glomerulonephritis in pregnancy and shares with other immunologic diseases and kidney diseases a relationship with adverse maternal outcomes, whose entity and pattern is only partially quantified. Recent studies provide new information and a systematic review regarded progression of kidney disease. The discussion of the outcomes with respect to low-risk pregnancies may help to perfect the estimation of the risks, and to identify specific research needs. Methods: A search strategy was built on Medline, EMBASE and the Cochrane review for the period January 2000–April 2017, aimed at retrieving both case series (defined as with at least 6 pregnancies in women with IgA nephropathy) and case reports, to look into rare occurrences. All papers, with or without control groups, were selected if they reported on at least one pregnancy outcome, or on long-term kidney function. Search strategy, paper selection and data extraction were done in duplicate (PROSPERO N 42016042623). Meta-analysis of case series was performed with Metanalyst Beta 3.13. Case reports were analysed narratively. Results: The search retrieved 556 papers, of which 27 were included (13 series and 14 case-reports). The case series report on 581 women with 729 pregnancies. The analysis was performed in comparison to the available control groups: 562 non-pregnant controls were available for the analysis of progression of kidney disease. As for pregnancy related outcomes (preeclampsia (PE), pregnancy induced hypertension (PIH), preterm birth, small babies), we meta-analyzed the data with respect to the only series of low-risk pregnancies (1418 pregnancies). When compared with women who never got pregnant after diagnosis of IgA nephropathy, in the present meta-analysis pregnancy in women with IgA nephropathy was not associated with a higher risk of progression of kidney disease, possibly due to the overall preserved kidney function at baseline: end-stage kidney disease (OR 0.68; CI 0.28–1.65). Conversely, the incidence of adverse pregnancy-related outcomes was increased compared to low-risk controls: PE and PIH were more than ten-fold increased (OR 11.80; CI 7.53–18.48 and OR 10.39; CI 5.45–19.80), while the increase in risk of preterm birth and “low birth weight babies” was less marked (OR 3.37; CI 1.91–5.95 and OR 2.36; CI 1.52–3.66), a discrepancy suggesting the occurrence of “late” or “maternal” PE, that may affect less severely foetal growth or shorten gestation. In conclusion, in the present meta-analysis IgA nephropathy was not associated with an increased progression of kidney disease. The more than ten-fold increased risk of PIH and PE, in combination with a doubled risk of small babies, suggests the occurrence of “late” or “maternal” PE, usually less affecting early foetal growth. This finding may be of help in defining control policies, while further research is needed to guide clinical management.

Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature

“…The pattern is not classic superimposed preeclampsia (PE), or “maternal preeclampsia”, a term often employed to define the full blown picture of hypertension and proteinuria developing or worsening on the basis of a pre-existing maternal disease (very often CKD). However, this pattern suggests a non-specific CKD-induced placental-dysfunction, quite common in CKD, where proteinuria often increases or develops in pregnancy, with or without hypertension, and is associated with an increased risk of preterm delivery and intrauterine growth restriction [6,7,38,39,40,41,42]. The presence of a worsening of kidney function led to the decision to induce delivery, also due to the search for a compromise between maternal and foetal health.…”

Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

“…As it will be further discussed, our knowledge on the specific risks linked with the different kidney diseases is limited; overall, we know more about glomerular diseases, and the most common ones, such as IgA nephropathy, are extensively studied; conversely, the specific risks associated with interstitial nephropathies or polycystic kidney disease (ADPKD) are not fully appreciated [ 7 , 9 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ].…”

Acute IgA-Dominant Glomerulonephritis Associated with Syphilis Infection in a Pregnant Teenager: A New Disease Association

“…IgA nephropathy, which may present as intense proteinuria in pregnancy, was also a potential explanation, especially in the context of a recent infection [8,43,44].…”

“…Virtually all chronic kidney diseases, including those characterized only by a reduction of the kidney parenchyma, are associated with an increased risk of PE [4,5,6,7,8,9,10,11]. Interestingly, these forms of “superimposed” PE are associated with a peculiar pattern of angiogenic-antiangiogenic biomarkers, which differs from the more common forms of PE, not related to pre-existing kidney disease [12,13,14,15].…”