Clinical practice guideline on pregnancy and renal disease

Abstract

The aim of this guideline is to improve the standard of, and to reduce regional variation in, the care of women with CKD in the UK who are pregnant, planning a pregnancy or post-partum. Scope This guidance covers the care of women with CKD (including renal transplant recipients) who are planning a pregnancy, pregnant, or in the post-partum period. It also covers contraception and fertility for women with CKD. This guideline can be used in the following settings: General practice Community and hospital antenatal clinics Antenatal, labour and postnatal wards Renal outpatients Renal wards Dialysis units The target audience and intended users of this guideline are nephrologists, obstetricians, obstetric physicians, midwives, renal nurses, pharmacists, specialist trainees in both nephrology and obstetrics, and women with CKD who are pregnant or considering pregnancy. Qualitative data on the experience of pregnancy and renal disease is provided in Appendix 1. A summary of clinical responsibility for elements of the guideline is provided in Appendix 2. The clinical issues covered in this guideline are: Structure of care Medication Pre-pregnancy care 3.1.Contraception 3.2.Fertility 3.3.Pre-pregnancy counselling and optimisation for pregnancy Pregnancy care 4.1 Assessment of renal function in pregnancy 4.2 Antenatal care 4.3 Pre-eclampsia prophylaxis 4.4 Blood pressure management 4.5 Thromboembolism prophylaxis 4.6 Anaemia 4.7 Bone health 4.8 Renal biopsy 4.9 Peripartum care 4.10 Postnatal care Pregnancy Care Assessment of renal function in pregnancy Guideline 4.1.1 We recommend renal function in pregnancy is assessed using serum creatinine concentrations as estimated GFR (eGFR) is not valid for use in pregnancy (1C). Guideline 4.1.2 We recommend women with CKD have formal quantification of proteinuria in pregnancy (1D). Guideline 4.1.3 We recommend quantification of proteinuria is undertaken by protein:creatinine ratio (uPCR) or albumin:creatinine ratio (uACR). Twenty-four hour urine collection for quantification of protein is not required (1B). Antenatal care Guideline 4.2.1 We suggest pregnant women with CKD who have not had pre-pregnancy counselling by the MDT are referred to the MDT and receive the same counselling and optimisation as for women attending pre-pregnancy (2D). Guideline 4.2.2 We recommend pregnant women with CKD receive routine antenatal care, in addition to specialist input (1D). Guideline 4.2.3 We recommend pregnant women with CKD be referred for assessment by a consultant obstetrician (1D). Guideline 4.2.4 We recommend pregnant women with CKD have access to usual trisomy screening with specialist interpretation of high-risk results (1C). Guideline 4.2.5 We recommend women with CKD exposed to teratogenic drugs in the first trimester are referred to a specialist fetal medicine unit (1D). Guideline 4.1.6 We recommend pregnant women with CKD have scans to assess fetal growth and wellbeing in the third trimester (1C). Guideline 4.2.7 We recommend pregnant women taking prednisolone and/or calcineurin inhib...

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“…To be avoided, as it provokes diuresis in fetus and possibly volume depletion/placental perfusion Recently published clinical practice guidelines in pregnancy and renal disease from the UK Renal Association (RA) recommends the use of thromboprophylaxis in patients with nephrotic range proteinuria, and considering its use in patients with non-nephrotic proteinuria when additional risk factors are present. 21 Patients with systemic immune mediated disease with kidney involvement are carefully evaluated at preconception to discard active disease, stratify risk and optimize timing of conception. Women with lupus nephritis and proteinuria >1g/day after ACE/ARB suspension should ideally be submitted to biopsy (prepregnancy) to exclude active nephritis, which is associated with unfavorable outcomes.…”

“…Calcium supplementation as a measure to reduce PE is not consensual and according to UK RA guidelines, it is not recommended in this population as it could increase positive calcium balance with cardiovascular long-term consequences. 21 BP monitoring at home is essential for the early diagnosis of PE. When BP increases, close surveillance is warranted, with antihypertensive drug adjustment, laboratory monitoring to detect organ repercussion and vigilance of fetal wellbeing.…”

“…Additionally, the guideline committee advocates that until there is strong evidence to intensify dialysis in patients commencing dialysis during pregnancy, initiation of dialytic therapy during pregnancy should be 'gentle' (example 2h 3times a week), with subsequent titration according to biochemical parameters, as well as maternal and fetal wellbeing. 21 As mentioned above, in patients with diabetic nephropathy, both glycemic and blood pressure control and proteinuria management must be optimized in preconception to reduce the incidence of complications, including malformations. During pregnancy, proteinuria frequently increases, due to hyperfiltration and an increase in glomerular permeability associated with the progressive rise of sFlt-1 level during gestation.…”

“…Recently published UK RA guidelines recommend switching from PD to HD and prescribing long, frequent hemodialysis, aiming for pre-dialysis urea < 75mg/dl. 21 Other authors will aim for pre-dialysis urea of 60-90 mg/dl and define that minimum dialysis dose in pregnancy will be typically 36h/ week (6h/day, 6 times a week). 37 At our unit, we aim for 36h/week, with urea < 60mg/dl, although this schedule is highly challenging for patients requiring individualization, especially in patients with residual renal function.…”

“…Non-steroidal anti-inflammatories (NSAIDs) are frequently prescribed as postpartum analgesics, but in women with CKD those agents should be avoided, especially in patients with eGFR <30ml/min due to the possibility of renal dysfunction or fluid retention. 21 After delivery, renal function and proteinuria should be evaluated, particularly in patients with acute kidney injury and/or de novo proteinuria/increased baseline proteinuria. In PE, proteinuria usually declines fairly rapidly, sometimes remitting entirely in the first month, although in some cases this can take months to happen.…”