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Renal disease in pregnancy 

Renal disease in pregnancy

Renal disease in pregnancy

John D. Firth

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date: 24 April 2017

Renal complications that can occur during pregnancy

Urinary tract infection—2 to 10% of pregnancies are complicated by asymptomatic bacteriuria, which progresses to symptomatic infection in 40% of cases and is associated with adverse fetal outcome. Antibiotic treatment reduces the chances of developing symptomatic infection and of infants being born with low birth weight.

Acute kidney injury—causes of particular note in pregnancy include (1) haemolytic uraemic syndrome (HUS, idiopathic postpartum renal failure)—typically presents 1 day to several weeks after delivery with rising creatinine and microangiopathic haemolytic anaemia, often in association with cardiac failure and neurological dysfunction; treatment is with supportive care and infusion of fresh plasma or plasma exchange. (2) Obstetric acute renal failure—responsible for about 1% of cases of acute renal failure in the developed world, but up to 30% in some countries; often caused by septic abortions and/or poor perinatal care; may be due to acute cortical necrosis with risk of permanent renal failure.

Pregnancy in women with known renal disease

Immediate effects of pregnancy include increase in proteinuria (50% of cases), development of or deterioration in hypertension (25%), and marked worsening of oedema.

Outcome in relation to baseline GFR—(1) GFR normal or mildly reduced (serum creatinine <125 µmol/litre, eGFR >45; CKD stages 1, 2 and 3A)—pregnancy is most unlikely to be associated with permanent decline in renal function and there is a greater than 90% chance of a successful obstetric outcome. (2) GFR is moderately reduced (serum creatinine 125–250 µmol/litre, eGFR 20–45; CKD stages 3B and 4)—about 40% will have a rise in creatinine during pregnancy (instead of the usual fall), up to one-third will have a greater than expected irreversible decline in GFR, and around 10% will progress fairly rapidly to endstage renal failure. Preterm delivery will be required in 60% of pregnancies because of pre-eclampsia and/or intrauterine growth retardation, but overall there is an approximately 90% chance of a successful obstetric outcome as long as blood pressure is well controlled. (3) Serum creatinine >250 µmol/litre (eGFR <20; CKD stages 4 and 5)—women with such gross impairment of renal function are rarely fertile. Pregnancies are not common in women receiving dialysis treatment, but with intensive management (including haemodialysis six times per week) about 50% result in (premature) live births. Successful renal transplantation restores fertility.

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