Course of membranous nephropathy during multiple gestations

Abstract

DESCRIPTIONThe physiological adaptations in pregnancy can unmask underlying occult proteinuric renal disease. However, the effect of multiple pregnancies on the course of the disease is variable. We report the clinical course of a case of idiopathic membranous nephropathy through multiple pregnancies.A 25-year-old Hispanic woman was referred to our institution for worsening generalised swelling of the body, uncontrolled hypertension and 21 g/day of proteinuria at 34 weeks' gestation during her third pregnancy. There were no stigmata suggestive of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. She was previously seen at our institution 5 years ago during her 1st pregnancy when 13 g/day of proteinuria was recorded at 25 weeks of gestation. At that time, she was treated with oral steroids and delivery was induced at 35 weeks due to intrauterine growth restriction. Placental biopsy revealed focal, tightly adherent blood clot, consistent with possible abruption. Renal biopsy performed in the postpartum period was consistent with membranous nephropathy (figure 1).She was treated with ACE inhibitors (ACEI) and at 3-month follow-up, she was asymptomatic, without oedema and urine protein-creatinine ratio (UPCR) had decreased to 7 g/g. She was lost to follow-up for 5 years until this recent admission. In the interim, she apparently had a second successful pregnancy but no data was available. During current pregnancy, delivery was induced at 34 weeks and the placental biopsy showed that it was critically small for gestational age and had focal intervillous fibrin deposition together with focal calcifications in the areas of more significant ischaemia (figure 2). Serology for antinuclear antibody, anti-double-stranded DNA, antiphospholipid antibody, viral hepatitis and rapid plasma regain were negative. Serum complements were within normal limits. During both the pregnancies, she had hypertension with average blood pressures in the range of 140-150/80-90 mm Hg, which is higher than expected for a normal pregnancy but within acceptable range for patients with preexisting chronic hypertension. At 1-month postpartum, UPCR was 1.8 g/g, without any treatment. Interestingly, her serum creatinine ranged between 0.6 and 0.9 mg/dL during this 5-year period. The patient was once again lost to follow-up. Learning points▸ Although there is physiological increase in proteinuria during pregnancy, the presence of nephrotic range proteinuria with or without hypertension in any trimester is always pathological and may be associated with underlying renal disease and a poor prognosis.

Various faces of the same disease: membranous nephropathy in pregnancy - A case series

“…Despite renal disease, its etiology and duration, the presence of hypertension at the time of conception carries a 10.6 times higher relative risk of fetal loss compared to when blood pressure is well-controlled by therapy, or even when it is normal without therapy [7]. The impact of MN on maternal and fetal outcomes of pregnancy is still unclear given the observed different courses of subsequent pregnancies in patients with MN, or even the spontaneous remission of nephrotic syndrome in pregnant women with MN [14,15].…”