Challenges in Managing Pregnancy in Underserved Women with Chronic Kidney Disease

Abstract

Background: Chronic kidney disease (CKD) is a global public health problem and is linked to adverse outcomes during pregnancy; the high prevalence of CKD (3–6%) in women of childbearing age is of particular relevance in emerging countries where CKD prevalence is higher and resources are limited. Although CKD is a public health problem in Mexico, there is scant information on outcomes in pregnant CKD women in this country. We report maternal–fetal outcomes in a prospective cohort of poor, CKD pregnant women, and compare results with those of pregnant women without CKD. Methods: A prospective study of pregnant CKD women referred to a public obstetrics/nephrology clinic from July 2013 to December 2017; sociodemographic and clinical data, including complications and perinatal outcomes, were recorded. CKD was defined at referral as per KDIGO guidelines; preeclampsia and superimposed preeclampsia were defined as appearance or worsening of hypertension and proteinuria. Findings were compared to official data for ­Mexico and to a historic control of pregnant women without CKD who delivered at our hospital. Results: Sixty-two pregnancies in CKD patients, age 23.4 ± 5.8 years were observed; 46.8% of patients were primiparous. At referral, serum creatinine was 1.8 (1.1–3.0) mg/dL with an estimate glomerular filtration rate (eGFR) of 38.1 (21.9–68.0) mL/min/1.73 m². In half of the cases, CKD was diagnosed during pregnancy. Forty-eight pregnant women without CKD, age 27 (22–34) years, who delivered during the study period were selected as controls: 33% were primiparous, serum creatinine was 0.50 (0.4–0.6) mg/dL, and estimate glomerular filtration rate was 135 (112–174) mL/min/1.73 m². Twenty patients needed dialysis (HD-CKD): 2 were already on dialysis, and 18 began treatment during pregnancy; 42 CKD patients did not require dialysis (non-HD CKD). After delivery, 15 patients remained dialysis dependent while 5 did not. Preeclampsia was more frequent in CKD patients in comparison to controls. In total, 93% of CKD patients and 98% of controls delivered a live baby. Prematurity was more frequent in CKD patients than controls and was higher in HD-CKD than in non-HD CKD. Birth weight was lower in CKD when compared to controls. Logistic regression showed a higher risk of preeclampsia in CKD pregnancies than in controls, but it was not affected by age, parity, CKD stage, or need for dialysis during pregnancy. Conclusions: Underserved CKD Mexican women have a high rate of adverse maternal-fetal outcomes during pregnancy. The risk may be higher in patients needing dialysis during pregnancy, many of whom remained dialysis dependent after delivery.

Pregnancy in women on chronic dialysis in the last decade (2010–2020): a systematic review

“…In our review, there were 287 (71.4%) live births among 402 pregnancies, varying between studies and ranging from 50% to 100%, probably due to the difference in dialysis schedules between countries [ 24 , 31 ], socioeconomic status and inequalities regarding access to healthcare around the world [ 13 , 20 , 21 ]. Preterm birth (<37 weeks of gestation) was the main, most common complication in all studies (82.8%), ranging from 50% to 100%, in keeping with other reports [ 28–31 ].…”

“…In the general population it has long been established that advanced maternal age alone is a risk factor for several pregnancy complications: gestational diabetes, hypertension, preeclampsia, increased risk of prematurity, death in utero , congenital anomalies, risk of placenta praevia and the likelihood of Caesarean section [ 16 , 18 , 41 ]. While adolescent mothers face higher risks of abortion, eclampsia, endometritis and systemic infections, their infants are at greater risk of low birth weight, preterm birth and serious neonatal conditions [ 13 , 18 , 38 , 42 ].…”

Impact of chronic kidney disease on fetomaternal outcome: a case report

“…In another study by Ibarra-hernandez et al, Mexican women were seen to have a higher rate of adverse fetomaternal outcomes needing dialysis during and after the pregnancy. 6 Hence, mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians in collaboration with nephrology team making combined management decisions is typically very helpful.…”

Diabetic nephropathy in type 1 diabetes and pregnancy. Modern view of the problem

“…принимали участие 62 беременные с ХБП (сывороточный креатинин 1,8 (1,1-3,0) мг/дл, рассчитанная СКФ 38,1 (21,9-68,0) мл/мин/1,73 м 2 ). Диализ выполнялся 20 женщинам (2 получали диализ на прегравидарном этапе, 18 потребовали лечения диализом во время беременности), 15 из них продолжили диализ после родов [60].…”

“…Однако высокий риск такой беременности как для матери, так и для плода очевиден: прогрессирование ДН, инвалидизация детей, финансовая и психологическая нагрузка на женщину и ее близких при терапии гемодиализом [15,21]. Таким образом, возможность пролонгирования беременности у женщин с тяжелой дисфункцией почек может быть рассмотрена только при условии настойчивого желания женщины, контроля основного заболевания, участия междисциплинарной врачебной команды, включающей акушера-гинеколога, нефролога, эндокринолога, психолога, офтальмолога, неонатолога, доступности гемодиализа для пациентки и, конечно, понимания женщиной возможных рисков при наступлении и вынашивании такой беременности как для нее, так и для ребенка [41,60].…”