Pregnancy in women with underlying renal disease
- Phyllis August, MD, MPH
Phyllis August, MD, MPH
- Ralph A Baer, MD Professor of Research in Medicine
- Director, Hypertension Center
- Division of Nephrology & Hypertension
- Weill Cornell Medical College
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
There are two questions that need to be addressed when a woman with underlying kidney disease becomes pregnant:
●What is the effect of pregnancy on the kidney disease?
●What is the effect of the kidney disease on pregnancy?
A review of issues relating to pregnancy in women with diabetic nephropathy is presented separately. (See "Pregnancy in women with diabetic kidney disease" and "Pregestational diabetes: Preconception counseling, evaluation, and management".)
EFFECT OF PREGNANCY ON KIDNEY DISEASE
When considering the effect of pregnancy on kidney disease, it is important to distinguish between changes in clinical manifestations and possible alterations in the long-term course of the disease. Proteinuria increases in approximately one-half of cases, and hypertension develops or worsens in approximately one-quarter of cases [1-6]. Severe hypertension can occur, potentially leading to maternal injury, premature delivery, or poor fetal outcome . Marked worsening of edema also can be seen in women with the nephrotic syndrome. These changes generally resolve after delivery.
- Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis 1999; 33:235.
- Hayslett JP. Interaction of renal disease and pregnancy. Kidney Int 1984; 25:579.
- Surian M, Imbasciati E, Cosci P, et al. Glomerular disease and pregnancy. A study of 123 pregnancies in patients with primary and secondary glomerular diseases. Nephron 1984; 36:101.
- Jungers P, Houillier P, Forget D, et al. Influence of pregnancy on the course of primary chronic glomerulonephritis. Lancet 1995; 346:1122.
- Bar J, Ben-Rafael Z, Padoa A, et al. Prediction of pregnancy outcome in subgroups of women with renal disease. Clin Nephrol 2000; 53:437.
- Rouse DJ, MacPherson C, Landon M, et al. Blood transfusion and cesarean delivery. Obstet Gynecol 2006; 108:891.
- Hou S. Pregnancy in women with chronic renal disease. N Engl J Med 1985; 312:836.
- Davison JM, Dunlop W. Renal hemodynamics and tubular function normal human pregnancy. Kidney Int 1980; 18:152.
- Imbasciati E, Pardi G, Capetta P, et al. Pregnancy in women with chronic renal failure. Am J Nephrol 1986; 6:193.
- Imbasciati E, Gregorini G, Cabiddu G, et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes. Am J Kidney Dis 2007; 49:753.
- Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med 1996; 335:226.
- Jungers P, Houillier P, Forget D, Henry-Amar M. Specific controversies concerning the natural history of renal disease in pregnancy. Am J Kidney Dis 1991; 17:116.
- Zhang JJ, Ma XX, Hao L, et al. A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy. Clin J Am Soc Nephrol 2015; 10:1964.
- Katz AI, Lindheimer MD. Does pregnancy aggravate primary glomerular disease? Am J Kidney Dis 1985; 6:261.
- Packham DK, North RA, Fairley KF, et al. Pregnancy in women with primary focal and segmental hyalinosis and sclerosis. Clin Nephrol 1988; 29:185.
- Packham DK, North RA, Fairley KF, et al. Primary glomerulonephritis and pregnancy. Q J Med 1989; 71:537.
- Lindheimer MD, Davison JM. Renal biopsy during pregnancy: 'to b . . . or not to b . . .?'. Br J Obstet Gynaecol 1987; 94:932.
- Fischer MJ, Lehnerz SD, Hebert JR, Parikh CR. Kidney disease is an independent risk factor for adverse fetal and maternal outcomes in pregnancy. Am J Kidney Dis 2004; 43:415.
- Piccoli GB, Attini R, Vasario E, et al. Pregnancy and chronic kidney disease: a challenge in all CKD stages. Clin J Am Soc Nephrol 2010; 5:844.
- Nevis IF, Reitsma A, Dominic A, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol 2011; 6:2587.
- Jungers P, Chauveau D. Pregnancy in renal disease. Kidney Int 1997; 52:871.
- Epstein FH. Pregnancy and renal disease. N Engl J Med 1996; 335:277.
- Cunningham FG, Cox SM, Harstad TW, et al. Chronic renal disease and pregnancy outcome. Am J Obstet Gynecol 1990; 163:453.
- Hou SH. Frequency and outcome of pregnancy in women on dialysis. Am J Kidney Dis 1994; 23:60.
- Gadallah MF, Ahmad B, Karubian F, Campese VM. Pregnancy in patients on chronic ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 20:407.
- Hou SH. Pregnancy in women on haemodialysis and peritoneal dialysis. Baillieres Clin Obstet Gynaecol 1994; 8:481.
- Bagon JA, Vernaeve H, De Muylder X, et al. Pregnancy and dialysis. Am J Kidney Dis 1998; 31:756.
- Okundaye I, Abrinko P, Hou S. Registry of pregnancy in dialysis patients. Am J Kidney Dis 1998; 31:766.
- Giatras I, Levy DP, Malone FD, et al. Pregnancy during dialysis: case report and management guidelines. Nephrol Dial Transplant 1998; 13:3266.
- Toma H, Tanabe K, Tokumoto T, et al. Pregnancy in women receiving renal dialysis or transplantation in Japan: a nationwide survey. Nephrol Dial Transplant 1999; 14:1511.
- Piccoli GB, Conijn A, Consiglio V, et al. Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counseling policy? Clin J Am Soc Nephrol 2010; 5:62.
- Hladunewich MA, Hou S, Odutayo A, et al. Intensive hemodialysis associates with improved pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol 2014; 25:1103.
- Jesudason S, Grace BS, McDonald SP. Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD. Clin J Am Soc Nephrol 2014; 9:143.
- Hou S. Modification of dialysis regimens for pregnancy. Int J Artif Organs 2002; 25:823.
- Hou S. Pregnancy in dialysis patients: where do we go from here? Semin Dial 2003; 16:376.
- Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis 1991; 17:127.
- Asamiya Y, Otsubo S, Matsuda Y, et al. The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 2009; 75:1217.
- Luders C, Castro MC, Titan SM, et al. Obstetric outcome in pregnant women on long-term dialysis: a case series. Am J Kidney Dis 2010; 56:77.
- Hull AR. More dialysis appears beneficial for pregnant ESRD patients (at least in Belgium). Am J Kidney Dis 1998; 31:863.
- Muirhead N, Sabharwal AR, Rieder MJ, et al. The outcome of pregnancy following renal transplantation--the experience of a single center. Transplantation 1992; 54:429.
- McKay DB, Josephson MA. Pregnancy in recipients of solid organs--effects on mother and child. N Engl J Med 2006; 354:1281.
- Gill JS, Zalunardo N, Rose C, Tonelli M. The pregnancy rate and live birth rate in kidney transplant recipients. Am J Transplant 2009; 9:1541.
- Levidiotis V, Chang S, McDonald S. Pregnancy and maternal outcomes among kidney transplant recipients. J Am Soc Nephrol 2009; 20:2433.
- McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005; 5:1592.
- Deshpande NA, James NT, Kucirka LM, et al. Pregnancy outcomes in kidney transplant recipients: a systematic review and meta-analysis. Am J Transplant 2011; 11:2388.
- Bramham K, Nelson-Piercy C, Gao H, et al. Pregnancy in renal transplant recipients: a UK national cohort study. Clin J Am Soc Nephrol 2013; 8:290.
- Sturgiss SN, Davison JM. Effect of pregnancy on the long-term function of renal allografts: an update. Am J Kidney Dis 1995; 26:54.
- Salmela KT, Kyllönen LE, Holmberg C, Grönhagen-Riska C. Impaired renal function after pregnancy in renal transplant recipients. Transplantation 1993; 56:1372.
- Rahamimov R, Ben-Haroush A, Wittenberg C, et al. Pregnancy in renal transplant recipients: long-term effect on patient and graft survival. A single-center experience. Transplantation 2006; 81:660.
- Lindheimer MD, Katz AI. Pregnancy in the renal transplant patient. Am J Kidney Dis 1992; 19:173.
- Bar Oz B, Hackman R, Einarson T, Koren G. Pregnancy outcome after cyclosporine therapy during pregnancy: a meta-analysis. Transplantation 2001; 71:1051.
- Sifontis NM, Coscia LA, Constantinescu S, et al. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation 2006; 82:1698.
- Jaffer S, Shynlova O, Lye S. Mammalian target of rapamycin is activated in association with myometrial proliferation during pregnancy. Endocrinology 2009; 150:4672.
- Thomson TC, Fitzpatrick KE, Johnson J. Intrinsic and extrinsic mechanisms of oocyte loss. Mol Hum Reprod 2010; 16:916.
- European Best Practices Guidelines (Part 2). Nephrol Dial Transplant 2002; 17 (Suppl 4):50.
- Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation 2000; 70:1718.
- Zheng S, Easterling TR, Umans JG, et al. Pharmacokinetics of tacrolimus during pregnancy. Ther Drug Monit 2012; 34:660.
- Xu LG, Wang HW, Peng WL, et al. Marital status and fertility of 185 male renal transplant recipients in China. J Androl 2008; 29:618.
- Zuber J, Anglicheau D, Elie C, et al. Sirolimus may reduce fertility in male renal transplant recipients. Am J Transplant 2008; 8:1471.
- EFFECT OF PREGNANCY ON KIDNEY DISEASE
- Effect on renal function
- Lupus nephritis
- Kidney biopsy during pregnancy
- EFFECT OF KIDNEY DISEASE ON PREGNANCY
- Pregnancy in mild to moderate chronic kidney disease
- - Drug therapy
- Pregnancy in the dialysis patient
- Pregnancy in the renal transplant recipient
- - Cyclosporine
- - Mycophenolate mofetil
- - Sirolimus
- - Tacrolimus
- - Glucocorticoids
- Male fertility after transplantation
- - Evaluation of renal dysfunction
- OBSTETRICAL MANAGEMENT OF WOMEN WITH UNDERLYING RENAL DISEASE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS