Maternal and foetal outcomes in pregnant patients with active lupus nephritis

Abstract

PURPOSE The objective of this study was to determine the impact of lupus nephritis disease activity on maternal and fetal outcomes in pregnant patients with systemic lupus erythematosus (SLE). METHODS Medical records of all pregnant patients with SLE treated at our institution between 1976 and 2007 were reviewed. All patients met American College of Rheumatology classification criteria for SLE. Demographic data, history of lupus nephritis, nephritis disease activity, and maternal and fetal outcomes of pregnancy were abstracted. Active lupus nephritis was defined as the presence of proteinuria > 0.5 g/day and/or active urinary sediment with or without an elevation in serum creatinine (Cr). Quiescent lupus nephritis was confirmed in the presence of proteinuria < 0.5 mg/day and inactive urinary sediment. RESULTS We identified fifty-eight patients with ninety pregnancies. Compared to pregnancies in SLE patients without renal involvement (n=47), pregnancies in patients with active lupus nephritis (n=23) were associated with a higher incidence of maternal complications (57% vs. 11%, p<0.001), whereas those with quiescent lupus nephritis (n=20) were not (35% vs. 11%, p=0.10). Women with active lupus nephritis were more likely to deliver preterm than women without lupus nephritis, median of 34 weeks vs. 40 gestational weeks, respectively (p=0.002), and were more likely to suffer fetal loss (35% vs 9%, p=0.031). CONCLUSION Active, but not quiescent, lupus nephritis during pregnancy is associated with a higher incidence of maternal and fetal complications compared to pregnancies in SLE patients without renal involvement.

A Systematic Review and Meta-Analysis of Pregnancy Outcomes in Patients with Systemic Lupus Erythematosus and Lupus Nephritis

“…Maternal deaths occurred because of opportunistic infections, sepsis, flares of lupus nephritis, and renal impairment (3,7,11,17,22,30,33,35). Of these deaths, three of the reported cases described the renal histologic subclass, and all had proliferative disease (7,17,22). Hemodialysis was rarely reported and included two patients who required hemodialysis during their pregnancies (32) and one patient who progressed to endstage renal disease and continued dialysis therapy (35).…”

“…Severe complications, including eclampsia, stroke, and maternal death, were observed in ϳ1% of subjects. Maternal deaths occurred because of opportunistic infections, sepsis, flares of lupus nephritis, and renal impairment (3,7,11,17,22,30,33,35). Of these deaths, three of the reported cases described the renal histologic subclass, and all had proliferative disease (7,17,22).…”

“…We also analyzed pregnancy outcomes by histologic subtype in a subset of papers that correlated renal histology with maternal and/or fetal outcomes (11,13,15,16,19,22,29,31,36). Because of limited data, we grouped histologic subclasses into proliferative (classes III and IV), and nonproliferative (classes II and V) lesions.…”

Flares of systemic lupus erythematosus during pregnancy and the puerperium: prevention, diagnosis and management

“…The risk for fetal loss in pregnant women with active lupus nephritis has been reported to range from 8 to 36% [6,[10][11][12]. However, pregnancy outcomes can be favorable in patients with a past history of lupus nephritis, particularly if the renal disease is in complete remission and renal function is normal at the time of conception [13,14]. Women with a serum creatinine of >2.8 mg/dl at the time of conception only have a 20-30% chance of pregnancy success [15].…”

The other side of the risk equation: Exploring the dangers of unplanned pregnancy in women with lupus nephritis. Comment on the article by Hahn et al

“…Although planning pregnancy is not feasible in many situations, and also because SLE does not affect fertility, we believe that prepregnancy counseling of women with LN remains a crucial target to aim for (23). Therefore, in our view, a recommendation that, as stated elsewhere, "contraception and the need to plan any pregnancy are discussed regularly during the routine care of the patients" (24) should be included in the text of the guidelines before dealing with the management of pregnancy with clinically active LN.…”