Kidney Diseases and Pregnancy: A Multidisciplinary Approach for Improving Care by Involving Nephrology, Obstetrics, Neonatology, Urology, Diabetology, Bioethics, and Internal Medicine
Abstract
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Conflicts of Interest
References
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Question | Key Points |
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Is it there a risk threshold for discouraging/forbidding pregnancy in CKD? | None established, context-sensitive, and insufficient evidence of counselling for women with severe or rare conditions. |
What is the role of the physician in counselling? | No model of physician–patient interaction is deemed superior to others and the role is context-sensitive (paternalism, therapeutic alliance, informative, etc.). |
In pregnancies that are at a high risk for early pre-term delivery, what is the weight of the associated risks for the baby? | This is an example of maternal–foetal conflict: pregnancy in dialysis, with stages 4–5 CKD (proteinuria and hypertension, or with a failing kidney graft) is associated with early pre-term delivery and small babies. The mother’s right to self-determination may conflict with the risk of disability in the offspring. |
What is the importance of the risk of impairing residual kidney function (or causing loss of a kidney graft) in a high-risk CKD pregnancy? | This is an issue that has an individual valence (risk of end-stage kidney disease) and a social one (costs of renal replacement therapy and competition for kidney transplantation). |
What is the role of genetic counselling and genetic selection in patients with late-onset diseases? | This is the case, for example, for polycystic kidney disease, whose high genetic frequency does not correspond to clinical disease. It generally develops in the 3rd and 4th decade of life, making it difficult to foresee what CKD treatment will be available when the disease becomes clinically overt in the offspring. |
Question | Key Points |
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What is the interaction between the different renal determinants of pregnancy outcomes (hypertension, proteinuria, and kidney function)? | Each of these factors has been independently associated with adverse pregnancy-related outcomes; their hierarchy, if any, is not known. |
Are there specific differences between the various kidney diseases? | Because of the high heterogeneity of CKD, little is known about the effect different kidney diseases have on pregnancy. |
What is the role of initial kidney tissue damage in hypertensive or diabetic pregnancies? | Risk factors for preeclampsia are almost all the same as risk factors for the development of CKD. Initial kidney damage may be the final pathway to adverse pregnancy outcomes. |
What is the best BP target in CKD or diabetic pregnancies? | The target blood pressure probably depends on control policy. If this is true, stricter controls should allow for safer normalisation. |
What is the best frequency of controls in the different CKD stages? | Even if CKD is presently acknowledged as a risk factor in pregnancy, the best policies for follow-up and controls have not yet been established. |
When and how should dialysis be started in pregnancy? | The recent literature shows improved results in dialysis patients. When to start dialysis in pregnancy has not been established. An early start may be an option, but it is in contrast with the data suggesting that a later start is safer in all other cases. |
What is the role of nutritional management of CKD pregnancies? | Nutritional management can probably compensate for deficits and balance the metabolic derangements of CKD, but its role has to be established. |
What should be done in the case of ‘forbidden’ potentially teratogen medications in pregnancy? | There is a wide variety of risks and phenotypes, and the echographic findings are usually available too late. |
How should the indications for managing CKD pregnancies be adapted to low- to medium-income countries? | Most of the indications for the care of pregnancies in CKD and related diseases have been defined in high-income countries. Their adaptation to low- to medium-income countries are difficult if not impossible. |
Question | Key Points |
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Should all pregnant patients have a kidney-function assessment? | Serum creatinine is an inexpensive test that could allow us to detect, at least, severe kidney diseases. |
What is the role of urinary culture control in preventing severe urinary tract infections? | Urinary infections are usually asymptomatic in pregnancy. Their systematic detection is included in some, but not all, of the guidelines for pregnancy care. |
What is the best policy of controls to prevent recurrent pyelonephritis or urinary tract infections in pregnancy? | Once detected, urinary tract infections in pregnancy should be treated. The frequency of subsequent controls, the role of echography, and of long-term prophylaxis need to be established. |
What is the clinical role of the angiogenic-antiangiogenic biomarkers in pregnancy? | These controversial markers may support the diagnosis of diseases other than preeclampsia, which is usually self- evident. |
When a woman has experienced acute kidney injury or preeclampsia, what follow-up should she have in the subsequent pregnancies? | After preeclampsia, the risk for developing a further hypertensive disorder of pregnancy is increased. However, these pregnancies are not uniformly identified as at risk and followed accordingly. |
What should the follow-up be for women who have experienced acute kidney injury or preeclampsia after pregnancy? | Even if preeclampsia in pregnancy indicates a long-term risk for CKD, follow-up indications have not been established. |
What should be done in the case of ‘forbidden’ potentially teratogen medications in pregnancy? | There is a wide variety of risks and phenotypes. The echographic findings are usually available too late. |
How should the indications of the management of preeclampsia, diabetes, and other diseases potentially affecting the kidney in pregnancy be adapted to low- to medium-income countries? | Most of the indications for follow-up and the care of pregnancies in CKD and related diseases have been defined in high-income countries. Their adaptation to low- to medium-income countries will be difficult if not impossible. |
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Piccoli, G.B.; Attini, R.; Cabiddu, G. Kidney Diseases and Pregnancy: A Multidisciplinary Approach for Improving Care by Involving Nephrology, Obstetrics, Neonatology, Urology, Diabetology, Bioethics, and Internal Medicine. J. Clin. Med. 2018, 7, 135. https://doi.org/10.3390/jcm7060135
Piccoli GB, Attini R, Cabiddu G. Kidney Diseases and Pregnancy: A Multidisciplinary Approach for Improving Care by Involving Nephrology, Obstetrics, Neonatology, Urology, Diabetology, Bioethics, and Internal Medicine. Journal of Clinical Medicine. 2018; 7(6):135. https://doi.org/10.3390/jcm7060135
Chicago/Turabian StylePiccoli, Giorgina Barbara, Rossella Attini, and Gianfranca Cabiddu. 2018. "Kidney Diseases and Pregnancy: A Multidisciplinary Approach for Improving Care by Involving Nephrology, Obstetrics, Neonatology, Urology, Diabetology, Bioethics, and Internal Medicine" Journal of Clinical Medicine 7, no. 6: 135. https://doi.org/10.3390/jcm7060135