Pregnancy in CKD Stages 3 to 5: Fetal and Maternal Outcomes
Received 20 October 2006; accepted 27 March 2007.
Refers to article:
Pregnancy and CKD: Any Progress?
Marshall D. Lindheimer, John M. Davison
American Journal of Kidney Diseases
June 2007 (Vol. 49, Issue 6, Pages 729-731) Full Text |
Full-Text PDF (58 KB)
Background
Prognostic criteria to inform women with moderate to severe renal insufficiency who wish to bear children are not well established.
Study Design
Longitudinal multicenter cohort study.
Settings & Participants
Nondiabetic white women with pregnancies proceeded beyond the 20th week and estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 (<1 mL/s/1.73 m2) before conception.
Predictors
Baseline GFR and proteinuria (exposure); other clinical characteristics at conception (covariates).
Outcomes & Measurements
Difference in GFR decreases before conception versus after delivery (mixed linear models); low birth weight (<2,500 g), and maternal renal survival (logistic and Cox regressions).
Results
49 women were studied. Mean serum creatinine and GFR at conception were 2.1 ± 1 (SD) mg/dL (186 ± 88 μmol/L) and 35 ± 12 mL/min/1.73 m2 (0.58 ± 0.2 mL/s/1.73 m2), respectively. Overall mean GFR after delivery was less than before conception (30 ± 13.8 versus 35 ± 12.2 mL/min/1.73 m2 [0.50 ± 0.23 versus 0.58 ± 0.20 mL/s/1.73 m2]; P < 0.001), but the rate of GFR decrease did not change (0.55 ± 0.8 versus 0.50 ± 0.3 mL/min/mo [0.0092 ± 0.013 versus 0.0083 ± 0.005 mL/s/mo]; P = 0.661). Independent of potential confounders, the combined presence of baseline GFR less than 40 mL/min/m2 (<0.67 mL/s/m2) and proteinuria with protein greater than 1 g/d, but not either factor alone, predicted faster GFR loss after delivery compared with before conception (1.17 ± 1.23 versus 0.55 ± 0.39 mL/min/mo; difference, 0.62 mL/min/mo; 95% confidence interval [CI], 0.27 to 0.96 mL/min/mo [0.020 ± 0.021 versus 0.0092 ± 0.007 mL/s/mo; difference, 0.10 mL/s/mo; 95% CI, 0.005 to 0.016 mL/s/mo]). The presence of both risk factors, but not either alone, also predicted shorter time to dialysis therapy or GFR halving (N = 20; hazard ratio, 5.2; 95% CI, 1.7 to 15.9) and low birth weight (N = 29; odds ratio, 5.1; 95% CI, 1.03 to 25.6).
Limitations
Generalizability to other settings; study power.
Conclusion
In women with renal insufficiency, the presence of both GFR less than 40 mL/min/1.73 m2 (<0.67 mL/s/m2) and proteinuria with protein greater than 1 g/d before conception predicts poor maternal and fetal outcomes.
5Divisione di Nefrologia IRCCS Ospedale Maggiore, Milano, Italy
6Divisione di Nefrologia, IRCCS Casa di Sollievo della Sofferenza S. Giovanni Rotondo, Italy
7Divisione di Nefrologia Azienda Istituti Ospitalieri di Cremona, Italy
8Clinical Epidemiology Unit, Health Sciences Centre, Memorial University of Newfoundland, Canada.
Address correspondence to Enrico Imbasciati, MD, Via Vittadini 9, 20136 Milano, Italy.
Support: P.R. holds a young investigator award from the Italian Society of Nephrology for 2005 to 2006 and received funding from the European Union (Marie Curie Actions-OIF, proposal #021676) for 2006 to 2007. Potential conflicts of interest: None.
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